Horizon Blue Cross Blue Shield of New Jersey has introduced significant changes to its reimbursement policies, creating substantial challenges for healthcare providers. Effective October 18, 2024, Horizon will begin retroactively adjusting claims for an 18-month look-back period, targeting payments made for specific radiopharmaceutical agents. These changes impact Piflufolastat (A9595), Gallium Ga-68 (A9596), and Gadopiclenol (A9573).
The policy asserts that reimbursement for these radiopharmaceuticals was erroneously processed as independent payments. Going forward, Horizon will bundle payment for these agents into the reimbursement for the associated radiology or cardiology imaging services, such as PET scans or MRIs. As part of this adjustment, any payments received for these agents during the look-back period will be recouped or retracted.
Horizon has stated that these changes align with their reimbursement guidelines, which specify that:
- Radiopharmaceuticals and contrast agents billed with imaging services (e.g., PET scans, MRIs) are considered part of the primary imaging service reimbursement and are not eligible for separate payment.
- Materials used in CT or other radiographic studies are also bundled into the imaging service.
- Non-ionic contrasts, low osmolar contrast material, and isotopes for therapeutic purposes fall under the same non-reimbursable payment rules when billed separately.
This policy affects multiple lines of business, including commercial fully insured plans, Braven Health℠, the State Health Benefits Program (SHBP), the School Employees’ Health Benefits Program (SEHBP), and select Administrative Services Only (ASO) employer groups. Providers may see messages on Explanation of Payment (EOP) or 835 statements indicating claims have been adjusted due to these changes. For a detailed breakdown of the policy, visit Horizon’s official announcement: Horizon Reimbursement Policy Update.
The Implications for Providers
This policy has far-reaching repercussions for healthcare providers. Radiopharmaceutical agents like Piflufolastat and Gallium Ga-68 are critical for diagnosing serious conditions such as cancer. The financial strain caused by retroactive payment retractions may force providers to delay or discontinue offering PET scans or substitute these agents with less effective alternatives. These policy changes not only threaten the financial health of practices but also compromise the standard of care for patients. Patients could be negatively impacted, as these changes could lead to delayed or missed diagnoses, significantly affecting treatment outcomes for life-threatening conditions.
Your Practice’s Rights and Options
Although New Jersey insurance regulations allow retroactive retractions of this kind, providers are not without recourse. Practices impacted by these changes have the right to appeal overpayment demands, challenge the amounts being recouped, and defend their claims using legal, coding and equitable arguments. The appeal process requires a thorough understanding of the policy, coding standards, and healthcare reimbursement regulations.
How We Can Help
At Frier Levitt, we understand the complexities of these policies and the financial pressures they place on your practice. Our team of experienced healthcare attorneys provides a comprehensive review of claims to identify discrepancies and build a strong defense. We work closely with certified coders to ensure that claims are accurately reviewed and that all potential errors or misapplications of reimbursement policies are identified. By leveraging deep expertise in both legal and regulatory matters, we ensure that your practice is equipped to challenge unjust recoupments and maintain financial stability.
If your practice is facing an audit, overpayment demand, or retroactive recoupment from Horizon or another payor related to these changes, don’t wait to take action. Contact Frier Levitt today to discuss how we can assist in defending your practice against unfair reimbursement practices, protecting your financial interests, and preserving the quality of care you provide to your patients.
These reimbursement policy adjustments should not undermine your ability to deliver life-saving services. Reach out to us for a consultation, and let us help you navigate this challenging situation while securing the resources needed to continue serving your patients.
