Insurance

Horizon Responds to MSNJ Concerns about New Network Requirements 

On May 29, Horizon announced in a letter to its network physicians that they would need to be board certified and have full privileges at one of its network hospitals by April 2013. Needless to say, these requirements were simply not achievable by many physicians who had long-served Horizon as network providers. MSNJ’s CEO, Larry Downs, immediately reached out to Horizon’s top management about our concerns over the new network requirements. Horizon agreed to consider our position, and later offered to speak with each MSNJ member, individually, about the impact of its newly announced network requirements.

We are pleased that Horizon responded to our concerns by grandfathering current PPO providers from the board certification requirement. Horizon also established a number of exceptions to the requirement to have privileges at a network hospital. These include: physicians with valid Continuation of Care forms on file; anesthesiologists and pain management physicians who have privileges with at least one free-standing ambulatory surgical center; and a number of specialists, including: allergists, dermatologists, physiatrists, and ophthalmologists.

MSNJ appreciates Horizon’s prompt response and accommodations to the significant concerns of our members who have been long-standing network participants.

Physicians who may be affected by Horizon’s new network requirements are urged to read Horizon’s letter explaining the changes to its originally announced policy.

Largest Healthcare Fraud Settlement in U.S. History

Last week, the Department of Justice announced the largest healthcare fraud settlement in U.S. history. GlaxoSmithKline (GSK) agreed to pay $3 billion to resolve a number of criminal and civil lawsuits alleging: unlawful promotion--off-label uses; failure to report certain safety data; and false price reporting activity. The settlement resolves liability for off-label promotion of Paxil, Wellbutrin, Advair, Lamictal and Zofran, and for alleged kick-backs to physicians for prescribing Imitrex, Lotronex, Flovent and Valtrex. It also resolves alleged underpayments of rebates to Medicaid.

GSK entered into a five-year corporate integrity agreement which requires notice to physicians of the terms of the settlement and establishes a speaker monitoring program. Visit the DOJ website for details on the settlement agreements.

Governor Christie Vetoes Health Insurance Exchange (HIX) Legislation

Citing the unresolved health care issues before the U.S. Supreme Court, Governor Christie vetoed the HIX legislation yesterday. Read the press release and the Governor's veto message. MSNJ looks forward to working with the Governor and Legislature to help craft an exchange that will provide more options for New Jersey residents to obtain affordable healthcare insurance.

ICD-10 Delay Proposed in Unique Health Plan Identifier Rule

CMS published a proposed rule on April 9 that formally calls for delaying the implementation date of ICD-10 for one year, from October 1, 2013 to October 1, 2014. Read more.

MSNJ Leads Rule-making that Directly Impacts Physicians

Two state regulatory proposals will have a direct impact on virtually every member of MSNJ and physicians practicing in New Jersey. DOBI’s re-proposed regulation on managed care contracts is the culmination of seven years of MSNJ work, beginning with the passage of the managed care reform law in 2006 and the settlement of national class-action lawsuits with the major healthcare insurers over the past decade. One element of managed care reform is regulations that will legally bind healthcare insurers to fair contract principles with participating physicians. MSNJ has tirelessly spearheaded this initiative, meeting with representatives at the highest level of both DOBI and the Governor’s Office. This has caused the re-proposal to be released for comments.

Similarly, DOBI re-proposed regulations governing the personal injury protection (PIP) program in New Jersey when MSNJ expressed concerns over the comprehensive rule proposal. This has already resulted in the removal of the proposed workers compensation managed care organization (WCMCO) network. Read more.

MSNJ Comments on Health Insurance Exchange (HIX) Legislation

Last week, MSNJ submitted comments to the Senate Commerce Committee, regarding the Health Insurance Exchange (HIX) legislation, bill, A-2171 (Conaway, D – Burlington). MSNJ supports active purchasing, meaning the Board of the Exchange would scrutinize plans to determine if they should be offered through the HIX. MSNJ also advocates that practicing physicians be included in HIX implementation. We recommend that a separate, clinical advisory committee be created and given direct input into the board’s certification of health plans.