NJ Patient Care and Access Coalition

Since it first learned in late April of a surprise announcement by Horizon Blue Cross Blue Shield to implement a new policy to impose Medical Necessity Determinations (MND) on various ultrasound services, the New Jersey Patient Care and Access Coalition has been working virtually non-stop to reverse this illadvised decision.

The new Horizon program requires a referring physician to obtain an MND for a variety of obstetric and non-obstetric ultrasounds (the “MND Program”). NJPCAC believes that this MND requirement is a first-of-its-kind in the State—at least outside of the Medicaid program.

NJPCAC further believes that the MND Program will harm patients with serious urologic and gastrointestinal conditions by creating unnecessary delays in patient care and increased patient costs, while imposing significant burdens on the physician practices that order ultrasound services.

Working with other physician specialties, including OB-GYNs, and the Medical Society of New Jersey, NJPCAC was able to get a quick and necessary delay in the implementation date from May 1st to June 3rd. On May 15th, Horizon indefinitely postponed the policy posting this to their webpage:

Ultrasound Services Program Delayed Until Further Notice

We previously announced that Horizon BCBSNJ would implement Medical Necessity Review (MNR) for certain obstetrical and non-obstetrical ultrasound procedures and services beginning on June 3, 2019.

This program has been delayed until further notice.

We are reviewing current program guidelines and criteria in preparation for our implementation at a future date. We will advise you of further program updates on HorizonBlue.com/providernews.

If you have any questions, contact your Network Specialist, Ancillary Contracting Specialist or Hospital Network Specialist.

NJPCAC leadership met with Assembly Health Committee Chairman Dr. Herb Conaway in late April. Dr. Conaway was briefed on the issue and asked to intervene on our behalf. The Chairman scheduled a rare State House hearing to address the issue and invited NJPCAC physicians to testify.

At the eleventh hour, on the Friday before the scheduled Monday, May 13th hearing, Horizon notified NJPCAC and Chairman Conaway that it would put an “indefinite hold” on the new policy and began reaching out to NJPCAC and others to schedule a meeting in Newark to discuss the MND Program’s implications.

This is a clear victory for the patients our NJPCAC member practices serve. NJPCAC will continue to monitor the issue and work to ensure that the MND Program applied to critical ultrasound services is permanently rescinded.