Horizon Blue Cross Blue Shield of NJ has decided to partner with a utilization review company called American Specialty Health Network (ASH) to manage claims for acupuncture, chiropractic, occupational therapy, physical therapy and speech therapy. The potential union of Horizon and ASH is scheduled to begin January 1, 2020, pending approval by the New Jersey Department of Insurance (DOBI).
Why is this bad for patients – the nearly 3.8 million insured by Horizon?
Based upon information received from multiple credible sources, it is our opinion that the following improper practices will carry over to Horizon insureds:
• Routinely denies medically necessary care with unreasonable standards that are out of line with widely accepted standards of care, often after just 5 visits, which leaves the remainder of the 30 visits most Horizon plans allow unused for which patients have paid premiums for.
• Requires documentation to be reviewed after pre-determined amount of visits based on the doctor’s claim history, not the patient’s condition or history
• Has a history of administrative delays in processing requests for care and issuing payments
• Has a history of cost-shifting administrative costs of their services into medical costs to the patient
• Coerces patients into paying for their own care entirely out of pocket by denying reasonable and medically necessary care and encouraging providers and patients to sign waivers acknowledging the care is not medically necessary and paying for it themselves.
Our concern is with our patients having access to the care outlined in their Horizon health plans. In our opinion, ASH has a history of inhibiting access to care as evidenced by it being the subject of at least three large class action lawsuits in the past year alone. Below is a summary of those lawsuits:
Cigna Corp. and American Specialty Health Group, Inc. in May of this year reached an $11.75 million settlement in a class action lawsuit brought on behalf of all out-of-network chiropractors who had claims improperly denied. According to the lawsuit:
• ASH used improper and inconsistent practices to routinely deny services that were medically necessary, failed to take into account the individual conditions and needs of each patient, and used rigid internal guidelines that conflicted with generally accepted standards of care within the chiropractic profession, as well as Cigna’s own policies.
• ASH’s utilization review process led to arbitrary and capricious denials of coverage and restrictions on patient care.
Class-action lawsuit accuses Cigna of cost-shifting scheme to divert administrative charges
• The lawsuit filed in April 2018 in Pennsylvania accused Cigna of falsifying Explanation of Benefits
(EOB) forms to misrepresent charges from American Specialty Health.
• The suit further argued that the scheme could mean Cigna is reporting inaccurate Medical Loss
Ratios, used to calculate the percentage of premium income versus medical expenses.
Law suit against ASH and CIGNA for cost-shifting in California
• The lawsuit filed on May 23, 2018, in the Southern District of California for charging members for
what appeared to be medical expenses for therapy services but were actually charges for ASH’s
• Plaintiffs assert that ASH and CIGNA breach the Employee Retirement Income Security Act by
concealing material information about ASH’s charges on the patient EOBs.
Use this link to let the governor and your state representatives know that you do not want ASH to manage care for Horizon Blue Cross Blue Shield. It will take you to an easy to fill out form that will contact decision makers in the NJ government regarding this issue. Horizon plans to manage national and in state plans using ASHN. Act now and tell the Department of Banking and Insurance (DOBI) that this is a bad deal for anyone insured under Horizon and you like your insurance the way it currently is.
If you have any doubt about who ASHN is, you may want to read our blog post from 2010. This is all true, Read it here. There is a reason physical medicine providers such as PT, and chiropractors are alarmed at this.