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Horizon, doctors reach tentative settlement


NEWARK, N.J.--Horizon Blue Cross Blue Shield of New Jersey has reached a tentative settlement in a 2002 class action lawsuit filed by a group of doctors claiming the insurer either delayed or withheld payments to them.

Under the settlement reached on Monday, the Newark, N.J.-based insurer agreed to make "significant business practice improvements" to increase transparency in its interactions with physicians, according to a joint statement issued by the insurer and the doctors' attorney, Eric D. Katz, a partner in Nagel Rice & Mazie L.L.P. in Roseland, N.J.

The changes include: making fee schedules for common procedures available to participating physicians on CD-ROM or electronically; disclosing significant changes in its automated claims processing system; providing 90 days notice to participating physicians of material changes to contracts, policies and procedures; allowing primary care physicians to close their practices to new patients covered by Horizon BCBSNJ; and not reducing fees to participating physicians more than once a year.

In addition, Horizon agreed not to try to recover overpayments to physicians after more than 18 months of the original payment as well as provide more notice and information regarding overpayments. The insurer also agreed not to revoke a determination of medical necessity unless there is evidence of fraud, material error or material change in the condition of the patient prior to service.

However, under the tentative settlement, the insurer would make no payments to physicians and would not admit any wrongdoing.

The settlement is subject to approval by Judge Stephen Bernstein in New Jersey Superior Court, Essex County. If approved, the settlement would end litigation filed on behalf of at least 40,000 New Jersey doctors.