The news of CarePoint Health’s out-of-network status with the state’s largest health insurer came as no surprise when it became official June 1.
But the New Jersey Association of Health Plans is trying to reignite the debate over surprise and out of network billing — a popular health care legislative debate last year which lost steam to the current front-runner: tiered networks.
All three CarePoint Health facilities in Hudson County have now officially become out-of-network with Horizon Blue Cross Blue Shield of New Jersey.
This includes Christ Hospital in Jersey City, Bayonne Hospital in Bayonne and Hoboken University Medical Center in Hoboken, with the last two pulling out in May and June 1, respectively.
The move was criticized by the New Jersey Association of Health Plans president Wardell Sanders, who said this increases the chances of surprise thousands-of-dollars patient bills — which CarePoint has been known for.
“The problem of price gouging and surprise billing just got bigger for New Jersey consumers, the State Health Benefits Program, the State Treasury and public employees,” Sanders said. “The governor’s proposed 2017 budget calls for $250 million in health care cost savings, yet CarePoint’s departure from the Horizon network will only exacerbate the challenges of rising health care costs for the state and other employers.”
CarePoint spokesman Jarrod Bernstein said, “Being out of network is not a business strategy it is a survival strategy. Since rescuing our hospitals from bankruptcy when we acquired them, we have invested tens of millions of dollars in technology and programs to care for ALL that we serve regardless of their ability to pay.”
Horizon said that since being out of network in June 2015, CarePoint’s Jersey City facility, Christ Hospital, has billed the insurer more than $68 million.
“Out-of-network hospitals generally charge rates well above those agreed to by network hospitals and state law allows out-of-network hospitals to charge whatever they wish for their services,” Horizon said in a statement. “Under state regulations, insured individuals receiving emergency care at an out-of-network hospital are only responsible for paying the amount they would owe if treated at a network hospital. Insurance companies generally must pay the balance. Some out-of-network providers take advantage of this regulation to steer patients through their ER’s and charge substantially higher rates for services. These higher rates increase the cost of health insurance for everyone. “
Out-of-network and surprise billing were a hot button political issue just last year, but since then tiered network rules have taken over, leaving the issue unresolved.
Sanders said the news about CarePoint shines a light back on the topic.
“New Jersey’s current out-of-network regulations include a loophole that is taken advantage of by certain facilities and providers who engage in predatory pricing, surprising consumers with unexpected bills and creating exorbitant costs for consumers, employers and unions. New Jersey has become a hotbed for unconscionable out-of-network billing practices. The status quo is neither fair nor sustainable for health care consumers in New Jersey,” Sanders said. “It’s time for the Legislature to step in and protect consumers, unions, employers, the State and other payers from surprise bills and unfair pricing in emergency rooms.”
Bernstein also commented on the tiered network debate.
“New ‘tiered’ health insurance products being introduced into the market stand to drive commercially insured patients away from tier 2 providers like CarePoint Health, further reducing vital revenue from commercial payers that offset the underfunding of government payers like Medicaid and charity care,” he said. “We encourage policy makers to embrace an All-Payer system that adequately compensates community hospitals like ours as we preserve New Jersey’s social safety net.”
The data putting it at the top of the list came from the Centers for Medicare and Medicaid last June.
But a few months later, CMS’s parent division, the U.S. Department of Health and Human Services, chose CarePoint as a source of example for its peers.
“Today, the Centers for Medicare & Medicaid Services awarded $685 million to 39 national and regional collaborative healthcare transformation networks and supporting organizations to provide technical assistance support to help equip more than 140,000 clinicians with tools and support needed to improve quality of care, increase patients’ access to information, and spend dollars more wisely,” according to the announcement in September, which listed CarePoint among recipients.
In addition to the network concern, NJAHP accused CarePoint of not properly notifying patients through its website about the network status of health plans.
Sanders said the health system’s website is misleading because it lists insurers that it accepts, but does not specify which are in or out of network.
Bernstein replied, “We have gone to great lengths both online and off to make the community aware of our network status. Any statement to the contrary is false.”
Ahead of the anticipated move out of network with the state’s largest insurer, Hoboken pushed to move to a new health plan for city employees with United Healthcare.
In a letter to city employees in April, Mayor Dawn Zimmer said the move was better because in-network coverage would increase under the plan for both doctors and providers.
“Finally, by switching to UnitedHealthcare, our employees will continue to have access to all Carepoint Health facilities,” Zimmer said.
“CarePoint’s Hoboken University Medical Center provides essential healthcare services for our entire community, and I appreciate the investments they have made to ensure the highest level of service. My family’s primary care doctor is part of the hospital, and my entire family, including my children, husband, mother-in-law and myself have all received excellent care both at the hospital and through the family healthcare center. CarePoint helped the City of Hoboken navigate the healthcare battles in our State, and I appreciate that they are negotiating in good faith to reach agreements with healthcare providers to provide more in-network services,” she said.
But according to CarePoint, it is in network AmeriHealth and MagnaCare, but not with other major insurers, including Aetna, CIGNA, Oxford, Qualcare and UnitedHealthcare.
Bayonne, on the other hand, did not switch from Horizon for its health plans.
City spokesman Joseph Ryan said since New Jersey law covers emergency visits as in-network, there is no problem.
“Bayonne employees receive our health insurance through the State of New Jersey’s health benefits system. Through that system, most City of Bayonne employees have Horizon Blue Cross’s 20/30 plan as per collective bargaining agreements (union contracts). This covers hospitalization, office visits to doctors and other services. It is not just coverage for one hospital. The “20/30” refers to the fact that the copay is $20 for a visit to a primary care physician and the copay is $30 for a visit to a specialist. The emergency room copay is $125,” he said.
He added that the only issues arise if someone needs non-emergency care, but in that case there are other hospitals to go to in Jersey City or elsewhere.
Sanders said that while the law does exist, it only covers the 18 percent of commercially insured New Jersey residents. The remainder rely on care from state or federal health plans, which are the sources of reports that place CarePoint at the top of the list of most expensive hospitals in the country for the past two years.
Another point of contention Sanders raised was an emergency visit appointment tool. The idea of scheduling an emergency visit, or focusing on wait times, when the hospital community has been vocal about pushing patients into primary care offices seems like mixed signals, he said.
But CarePoint isn’t the only hospital to offer a scheduling tool or highlight emergency department wait times.
A quick online search shows Virtua Health, Inspira Health, The Valley Hospital and Morristown Medical Center also have similar tools.
The New Jersey Hospital Association replied that this is not supposed to be used to increase ED volume.
“These services are not intended to schedule non-emergency care in advance. They’re more of a “online check-in” to provide better service to people who are coming to the ED and hopefully alleviate some of their waiting time, and also to help hospitals anticipate the flow of patient demands. We agree wholeheartedly that emergency rooms are for emergent situations, and non-emergency needs should be handled in a more appropriate healthcare setting,” NJHA said.
Despite being out of network, CarePoint said it is willing to continue negotiations with Horizon.
“We remain open to continued negotiations in good faith with Horizon Blue Cross Blue Shield of New Jersey,” Bernstein said.