4 March 2017

Clinical Social Work/OPEIU Guild 49 Wins Legal Action Against State Employees Health Benefits Plan (Horizon BCBS)

Court reverses reduction of out-of-network reimbursement rate

(Wayne, New Jersey) September 5, 2013 -- The New Jersey Society for Clinical Social Work (NJSCSW)/OPEIU Guild 49 has won its legal action against the State Employees Health Benefits Plan (Horizon BCBS) for lowering their rate of reimbursement to out-of-network practitioners back in January 2009.  

The NJ State Appellate Division has decided that the lowering of reimbursement rates by the SHBP and Horizon was done in violation of N.J.S.A.52:14-17.46.7.  

This means that Horizon BCBS must reverse the reduction in reimbursement rates to LCSW's back to levels before 2009, said Luba Shagawat, MSW, LCSW, F-NAP, the director of legislative affairs for Guild 49. It's taken a long time to get this victory, but we are thrilled that the courts have reversed this injustice and returned the rate to a fair level. It proves the power of a collective voice, and what can be accomplished when workers unite for a common purpose.

The court found that the statute at issue does not authorize the Commission (Horizon) to deviate in any way, including rejecting the Prevailing Health Care Systems usual and customary (UCR) fee schedule, relying on non-nationally recognized database of prevailing health care charges to change that fee schedule, and imposing a percentage rate or condition the statute does not permit.  Thus the Commission's decision was arbitrary, capricious and unreasonable and must be reversed.   

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