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Horizon BCBS New Jersey allegedly underpaid ASC: 5 details to know

Premier Surgical Pavilion sued Horizon Blue Cross Blue Shield of New Jersey for allegedly using an improper formula to calculate reimbursements for benefits claims, Law360 reported.

Here are the key details to know:

1.Newark, N.J.-based Premier Surgical Pavilion alleged the reimbursements received from Horizon Blue Cross Blue Shield of New Jersey were calculated from a formula created by Navigant Consulting and were significantly lower than those issued by other Horizon programs.

2. Premier Surgical Pavilion also said Horizon Blue Cross Blue Shield of New Jersey disregarded the Employee Retirement Income Security Act through implementing the formula.

3. Horizon Blue Cross Blue Shield of New Jersey had a "duty" to the plans to give reimbursements based on the usual rates and disregarded the terms of the plans by not following through, Premier Surgical Pavilion alleged.

4. Premier Surgical said it was told Horizon Blue Cross Blue Shield of New Jersey used the Navigant allowance from around October 2004 to December 2014.

5. Premier Surgical is looking to recover benefits under ERISA "as the assignee of its patients' rights" and is asking for a finding that Horizon breached its fiduciary duties by not issuing the benefits.

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