Originally Published by By ROI-NJ, By Anjalee Khemlani; Trenton | Jul 1, 2019 at 10:00 am : http://www.roi-nj.com/2019/07/01/healthcare/third-party-auditor-bill-signed-into-law-despite-insurers-opposition/
Third-party auditor bill signed into law
A bill that some insurers lobbied quietly to quash made its way through the Legislature and was signed by Gov. Phil Murphy on Sunday.
The bill calls for a third-party auditor to real-time audit the State Health Benefits Plan and School Employees Health Benefits Plan.
It was first introduced in October 2018 by state Sen. Paul Sarlo (D-Wood-Ridge), and came from a report commissioned by a New Jersey doctor that alleged
health insurers were skimming off the top of claims payments for the SHBP and SEHBP.
The report was published by California-based AVYM.
ROI-NJ previously reported that the state’s contracts with Aetna and Horizon Blue Cross Blue Shield of New Jersey are set to expire this year, allowing a revamp of the Request for Proposal process and changing the type of contracts the state has with insurers who administer the state plans.
The Office of Legislative Services said in its fiscal analysis of the bill that it could not put a specific savings amount from the audited claims, even though
the AVYM report alleges savings of more than $1 million to the state.
“Hiring a third-party medical claims reviewer to provide regular, frequent and ongoing review and oversight of the claims process, which process includes, but is not limited to, the receipt, management, adjudication and payment of claims, serves the best interests of the state, participating employers and the thousands of employees and their dependents covered under the (SHBP and SEHBP),” according to the legislation.
The goal is to have a medical claims reviewer hired in time to review claims from plans that will be in effect in January 2020.
Horizon BCBSNJ has gotten worse, no better. In early 2020, Horizon BCBSNJ changed the NJ Direct plans. They state the SHBP initiated this change and began using the National Aggregate Fair Health benchmark data to determine out of network allowable for all Horizon BCBSNJ Direct plans. This is IN NETWORK and Medicare or lower reimbursement aside from the fact using a national aggregate defies the fundamental principle of how OON rates are determined. And they are getting away with it. This is devastating for out of network providers in the state of New Jersey as well as consumers paying for benefits they DO NOT HAVE.