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Tiered physician network raises ire in N.J.

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Payer-providers battles are heating up all over. Consider that Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) caused what FierceHealthPayer called “a firestorm of criticism from providers in the state when it announced  its new Omnia Health Alliance, a tiered physician network intended to cut healthcare costs and further the transition to value-based care.”

“The network’s critics say the insurer’s choice of providers to be included in its new network was neither fair nor transparent, ” but Horizon BCBSNJ CEO Bob Marino  told FierceHealthPayer that that they’re wrong.

“By offering lower deductibles, premiums and copays, Omnia’s tired-network health plans incentivize members to use what it calls Tier 1 providers, Marino says. Tier 1 includes six ‘value-based health systems,’ one large physician group and 14 additional Tier 1 hospitals chosen in order to expand members’ geographic access to care. If consumers or businesses chose to use Tier 2 providers, they will pay out-of-pocket costs similar to what they currently pay.”

“Additionally, Horizon intends to collaborate closely with the six value-based health systems and physician group that it hand-picked, a relationship Marino says will differ from the ‘typical payer-provider one-year relationship where you sit down and you talk about unit cost adjustments.’ With these providers’ help, the insurer will build infrastructure to integrate claims and clinical data to identify real-time gaps in care and pursue population health management goals.”

“But New Jersey health systems not included in Omnia’s Tier 1 have expressed confusion and frustration–particularly Catholic hospitals, which have suggested they were largely left out because of their religious affiliation,” the news service said.




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