MORRISTOWN, NJ - Horizon Healthcare Services, Inc., doing business as Horizon Blue Cross Blue Shield of New Jersey, has agreed to pay $100 million to settle allegations that it fraudulently induced the State of New Jersey into a multi-billion-dollar contract and systematically overcharged the State for healthcare services, Attorney General Matthew J. Platkin announced. The settlement is the largest ever obtained under New Jersey’s False Claims Act outside the Medicaid program.
According to a complaint unsealed this week, Horizon allegedly violated multiple provisions of the New Jersey False Claims Act (NJFCA), including making false claims, submitting false records, and fraudulently securing a 2020 third-party administrator (TPA) contract to manage the State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP).
“At a time when everyone is rightly concerned about the cost of their healthcare, it is simply unacceptable that an insurance company would seek to defraud our State and overcharge us while driving up the costs of healthcare for hundreds of thousands of dedicated public servants,” said Attorney General Platkin.
At the heart of the allegations is Horizon’s failure to follow a key cost-control mechanism in the 2020 contract known as the “lesser of” provision. This clause required Horizon to charge the State the lower of either the amount a healthcare provider billed or the pre-negotiated rate between the provider and Horizon....
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