Horizon Blue Cross Blue Shield of New Jersey will pay $100 million to the state to settle claims that it fraudulently secured a multibillion-dollar public-employee health plan contract and systematically overcharged taxpayers for years, Attorney General Matthew J. Platkin announced Friday.
The settlement marks the largest non-Medicaid False Claims Act recovery in New Jersey history, according to Platkin.
The state alleged that Horizon violated the New Jersey False Claims Act by misleading officials into awarding it a 2020 third-party administrator contract while concealing that it could not comply with a key cost-saving “lesser of” provision.
Under the provision, Horizon was required to bill the state the lower of either the provider’s actual charge or the insurer’s negotiated rate. According to the complaint, Horizon knew internally that it could not meet this obligation but still submitted a winning bid.
Over the life of the contract, the company allegedly submitted more than 1,000 false claims and sent inaccurate explanation-of-benefits statements to members, the state said.
If legal proceedings arise between an employee and employer, there may be a strong temptation to present the facts in a more favorable light than they actually are. If an employee makes false clai...