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View Diary: Urgency of public option: BC/BS sued for engaging in "life threatening business practices" (271 comments)

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  •  You should really look at (2+ / 0-)
    Recommended by:
    nyceve, An Affirming Flame

    the Bayonne complaint (pdf).  It's written in English (I assume it will fail in court for that reason) and gives quite a good explanation of why it failed in its pricing negotiations with Horizon, but that Horizon is bound to pay its current fees and stop harassing its patients anyway.

    •  Who failed whom? (2+ / 0-)
      Recommended by:
      rhutcheson, brein

      The complaint gives an interesting overview of medical care in New Jersey (and more than a few gratuitous swings at Horizon management), but again, it boils down to one thing: who determines the fees that a hospital may charge a carrier?  

      BHC wants to set a higher fee level.  Horizon wants to pay a lower fee level.

      BHC encourages patients to come to its urgent care facilities, because higher utilization allows it to bill more.

      Horizon discourages patients from going to BHC facilities, because Horizon gets higher bills for BHC treatment.

      It is beyond disgraceful that we have reached a point in this country that hospitals and carriers play these games with each other at the expense of creating a seamless network of health care providers.  I have written here in support of single payer.  I have no love for Horizon.

      Let's not pretend, however, that BHC is a group of saints.  They are suing Horizon to try to force Horizon to give BHC more money.  That's the entire extent of the debate.

      •  Yes, there's something to what you say - (2+ / 0-)
        Recommended by:
        brein, Taunter

        in fact, I'm not much of a fan of providers in their eternal battle for higher fees.

        However, in this case the responsible thing for Horizon to do would be to fulfill its commitment to its subscribers by contracting with an emergency room provider in that geographical area.  The Bayonne facility claims that its the only emergency room in the immediate area - a check with the on-line Yellow Pages and Horizon's own provider listings for hospitals seems to indicate, as the Bayonne hospital suit claims, that there is no participating facility in Bayonne.

        Now, an insurance company doesn't get 50% of the market, as Horizon has done, by being Mr. Nice Insurer.  But price and profit considerations do not allow a licensed insurer to sell products without providing promised benefits, as it seems Horizon is doing here.

        In the absence of an active state insurance commissioner (my prejudice: what else would you expect in New Jersey?), this kind of suit, whether filed by a provider or by a class of subscribers, seems to be the only appropriate remedy.

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