After battling with my Insurer Horizon Blue Cross Blue Shield (Horizon) and service provider Newark Beth Israel Medical Center (Barnabas Health) for 8 months; on 08-02-16 I filed a complaint against both of them with New Jersey Department of Banking & Insurance (NJDOBI).
In my complaint I accused Barnabas & Horizon of fraudulently fixing and approving exorbitantly very high prices for the services as compared to the market rates. I also accused Horizon that according to their own representative John, 08-02-16, the services availed by my son come under “Preventive Care Services”. So, there cannot be any deductible or coinsurance; it is 100% covered by Horizon. I mentioned that since 2003 I have been using Associates in Cardiovascular Diseases in Springfield, NJ 973 467 0005 and according to their billing department for a non-insured/self cash pay for Echo Study that includes Doppler, color flow and congenital they charge $305.00 and for EKG$21.32.
I also mentioned that for 8 months against my numerous verbal and written requests, Barnabas has refused to provide me the detailed bill with CPT codes for the test done for my son. He had an open heart surgery in 2004 at Beth Israel and is required to go for routine checkup every 5 years as an outpatient at Beth Israel aka Barnabas Heath. For the last visit in 2009 we were not billed anything. For the 12-14-15 visit Barnabas billed me for $2,556.88 as my share after receiving $853.27 from Horizon for the Test and NBIMC billed $60.20 as my share for the physician office visit and test interpretations after receiving $316.42 from Horizon. The original billing by Horizon was $4,122.00 and by NBIMC was $702.00. After discount / adjustment of $711.85 Horizon’s final bill was $3410.15 and NBIMC was $414.66 after discount of $287.34.
On 09-01-16 NJDOBI’s investigator Ms. Eileen Cashman-Jermak wrote to me that “All the information submitted by you (me) and the company has been thoroughly reviewed and it appears that the company’s actions are in accordance with the provisions of the policy contract, applicable statues and regulations. As a result, no further actions are required at this time.” In her letter she provided me the details for the test done along with CPT codes on behalf of Barnabas that they have refused to provide me for the last over 8 months.
The response of Ms. Eileen clearly indicates that she is not working for the consumers of the New Jersey; rather she is working for the Insurance company and the service provider. This I can safely say on the basis of the further investigations I did on my own:
I called Horizon Member Services on 09-08-16 and spoke to Ms. Lori Call ref # 1-5384124822U according to her All these testsunder CPT code 93303, 93320, 93325, 93005 & 94760 come under “Preventive Care Services” no deductible, no co-pay & 100%covered by Horizon.
Newark Beth Israel Medical Center aka Barnabas Health: (non-Invasive Cardiac Care)
09-08-16 I asked Ms. Giselle 973 926 7475 for a price quote for self-paying patient with no insurance for same diagnostic test as an outpatient. She told me that “we do not do CPT 93303 we have 93306 that covers 93303, 9320 & 9325 cost is $752.00 including physician charges for interpreting the results.For CPT 93005 & 94760 you have to call the other department. I asked them to put it in writing and fax/e-mail me the price quote. She told me her supervisor will send it to me. When I never received any fax/e-mail, next day on 09-09-16 I called Ms. Giselle again and she told me to talk to Ms. Arlene McGaugh 973 926 8294.
On 09-09-16 I spoke to Ms. Arlene McGaugh and she asked me to fax to 973 282 2432 the CPT codes for the test I want as self paying patient with no insurance. I received an e-mail at 12:08 PM from Jamie Ortiz that all the test CPT code 93303, 93320, 93325, 93005 & 94760 will cost $910.27 as cash/self pay out patient inclusive of physician charges.
All the above indicate that NJDOBI investigation and conclusions are totally flawed and are in favor of Horizon & Barnabas. May be Ms. Eileen never did any investigations!
- Why NJDOBI has not questioned Barnabas Health for not providing me the detailed bill along with the CPT codes despite my numerous requests? I did file documentary proof for the same on 08-02-16 to NJDOBI on this matter also. After 9 months NJDOBI provided me the CPT codes for the services providedto my son on behalf of Barnabas.
- Did NJDOBI raise any question to why Beth Israel never disclosed upfront what test they will be doing and what will be the tentative cost especially when the cost was$4,122.00 for the Test and $702.00 for the physician?
- NJDOBI could have called Beth Israel or any other facility to enquire about the charges for all the test and physician charges to verify my allegations made on 08-02-16 that Horizon & Barnabas are colluding with each other to inflate the prices of the services rendered on 12-14-15 to do consumer frauds in this case me.
- NJDOBI failed to question Horizon why they paid NBIMC $244.06 for “New Patient Office Exam” when my son is not a new patient.
- NJDOBI failed to verify my claim that services rendered on 12-14-15 comes under “Preventive Care Services” that attracts no deductible, no co-pay &Horizon must pay 100% for these services.
- Even if the Horizon disputes after disowning the 09-08-16 statement of their representative Ms. Lori that services under CPT code 93303, 93320, 93325, 93005 & 94760 comes under “Preventive Care Services”; why I will pay $2,556.88 to Barnabas on top of $853.27 already paid by Horizon and$60.20 as my share for the physician after $316.42 paid by Horizon when for the same services as Self Pay with no insurance Barnabas is asking$910.27 including physician interpretation charges for the test?
Horizon has a fiduciary duty to protect its policy holders/consumers but it has failed them miserably. Its CEO makes over $5 million and other executive close to or more than a million dollars and they still do not know how to negotiate prices for the services rendered by hospitals or doctors especially when they are providing them regular supply of patients. I don’t think they are brain dead or retarded otherwise they should not be occupying such top positions in Horizon with millions in compensation every year. It looks like Horizon executives are running scams for direct or indirect material benefits that’s why they approved $3,410.15 after so called negations from $4,122.00 for the test and $ 376.62 from $702.00 (office visit $473.00 & $229.00 for test interpretation) for the physician billed by NBIMC. Surprisingly the same Beth Israel aka Barnabas Health is selling these services for $910.27 to an individual with no insurance including physician’s interpretation charges. The scammers posing as Executives making millions of dollars at Horizon in their fiduciary duties are trying to prove to their policy holders that they negotiated the best prices for them! It is defying the centuries old business logic that when you buy in bulk the goods or services; the prices are much lower as buying 1 piece or buying a service one time only.
Since becoming the Chairman of Republican Governors Association in Nov 2013 Governor Christie first wasted his time on his non existent chance of US Presidential Candidate and then on VP of Republican front runner Donald Trump and currently he is dreaming of a Cabinet position in Trump government. That is the reason under the absentee Gov. Christie’s leadership NJDOBI has failed to regulate Horizon and Barnabas Healthcare. NJDOBI have no objections if Horizon& Barnabas can penalize me/consumer for having a self-paying individual Health Insurance Policy from the market place! Christie administration also has no objection if these companies are doing consumer frauds under the supervision of their own supervisory staff that has no desire to properly investigate complaints against them.
All of the above is happening because there is no government in New Jersey to protect the interest of its citizens. Rather New Jersey has been let down by its politicians across the aisle whether it was Bias intimidation law, HIB law, Domestic Terrorism law, consumer or child or women or senior citizens’ welfare. The NJ lawmakers pass laws without reading them and when you request them to make changes because it is hurting people even with well documented pitfalls; they write to you that we have to receive more complaints rather more victims of vaguely written laws before we make any changes! If you complain
Christie government and Christie himself if informed that the local government of your town is doing massive frauds; the concerned department and Christie will rarely acknowledge your complaint. They will toss it up to another department and they will toss up to some other department, this process of tossing up will continue till you give up your hopes for any justice. If you report consumer frauds by big companies, they tell you that the company is doing everything in accordance with the provisions under the applicable laws!
Mind it practically all the lawmakers of New Jersey are attorneys and running their own practices also. For all the anti-people policies created by dishonest politicians of both the parties, New Jersey is called a “Mafia State,” a state for 8.5 million residents with over 10,000 elected political scoundrels representing 587 local and 1 state government with over 630,000 employees! Under Christie’s mismanagement supported by the lawmakers of both parties, New Jersey’s credit rating has been downgraded nine times (across Standard & Poor, Fitch Ratings, and Moody’s Investors Service), leaving only Illinois with a lower rating among US states. Because of their collective hard work New Jersey rank 3rd with $35 billion debt for 8.5 mil residents after New York with 2nd place with $63 billion for 19.75 mil residents and California with 1ST place with $94 billion for 38.8 mil residents. In fact New Jersey rank number 1 in USA with per capita debt of $4,117.65 followed by New York with $3,189.87 at 2nd place and California with $2,422.68 at 3rd place.