Horizon to pay state $100M on fraud complaint of overcharging
By: Scott Fallon
NorthJersey.com
USA Today Network - New Jersey
..... Horizon Blue Cross Blue Shield, New Jersey's largest health insurer, has agreed to pay the state $100 million to settle claims that it defrauded the public employees' medical plan by overcharging for services, officials announced on November 14. [2025]
.....
Horizon executives intentionally violated a provision in its 2020 contract with the state that ensured New Jessey would never pay more for medical services than the amounts doctors, hospitals and other providers charged for them. Attorney General Matthew Platkin said at a news conference in Newark.
..... "Horizon never intended to keep that promise, nor did it," reads a lawsuit by Platkin against Horizon that was unsealed in federal court.
..... "If you can't live by [a contract's] terms, you don't have the option of lying and then hoping you don't get caught," Platkin said. "I would hope Horizon or any other company sees a 4100 million payment and realizes it's not worth the cost of doing that."
..... A Horizon spokesman blasted Platkin's description of the settlement, calling it part of a "disturbing pattern of significantly mis-characterizing and distorting facts to falsely allege intentional wrongdoing where not exists."
..... The dispute claims represented 0.07% of the 48 million claims that Horizon processed for the state over four years, he said.
..... "This has never been anything more than a straightforward contract dispute - one that Horizon tired to resolve in good faith more than four years ago in the same way it has resolved similar disagreements over the course of our long and fruitful partnership with the state - through a negotiated reimbursement," Tom Wilson, a company spokesman, said in a statement.
..... "The attorney general instead chose to waste time and taxpayer resources to achieve the same outcome and now tries to justify his decision to turn a contract dispute into a media circus by hurling loaded, false and dangerous accusations at Horizon for his personal and political benefit," Wilson said.
..... The "overwhelming majority" of the settlement will be going back into the state's health plan, which is seeing
large premium increases.
..... Platkin did not say how much New Jersey saws over-billed, but said it was small under the $100 million - the largest settlement under the federal false Claims Act in New Jersey history not involving Medicaid fraud.
..... Under the terms of the contract, if a doctor charged $500 for a service and Horizon had negotiated 41,000 for the same service, New Jersey would be charged $500. But Horizon violated that more than 1,000 times, the lawsuit said.
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Before they even submitted a bid for the contract, Horizon executives had analyzed claims and knew they wouldn't be able to abide the "lesser than" cost-saving provision, investigators said. They even discussed needing to "make the state whole on a retrospective basis," according to the lawsuit.
..... That allowed Horizon "to fraudulently secure" the four-year contract and receive nearly $500 million in fees form the taxpayer-funded plan.
.....
Wilson said Horizon executives began trying to resolve the dispute with the state in 2021 and made significant financial offers to address the disputed claims.
..... "Stripped of the attorney general's over-the-top rhetoric, this settlement resolves a contractual dispute concerning how a relatively small number of claims should have been paid," Wilson said.