By: Richard L. Smith
New Jersey officials have reached a historic $100 million settlement with Horizon Healthcare Services, Inc., concluding a multi-year investigation into claims that the insurer misled the State and overcharged its public employee health plans. 
The agreement, announced by Attorney General Matthew J. Platkin, is now the largest non-Medicaid False Claims Act settlement in state history.
According to information released by the Attorney General’s Office, the State alleged that Horizon fraudulently won a 2020 contract to administer health benefits for state and school employees by promising to follow a key cost-saving rule known as the “lesser of” provision.
The rule required Horizon to bill taxpayers the lower amount between a provider’s actual charge and the higher, pre-negotiated rate.
Investigators say Horizon knew it could not meet this requirement but bid anyway, then billed the State millions more than allowed and issued misleading Explanation of Benefits statements to members.
State Treasurer Elizabeth Maher Muoio said the Division of Pensions and Benefits began raising concerns in 2021, prompting an in-depth probe that confirmed widespread violations connected to the contract.
A whistleblower lawsuit filed later that year helped bring the matter into federal court, where New Jersey eventually filed its own complaint.
As part of the settlement, Horizon must pay the State within 25 days and comply with strict oversight measures to ensure accurate billing under its current contract.
The insurer has already stopped the disputed billing practices and incorrect EOBs. 
The agreement also directs $12 million to five whistleblowers involved in the original complaint.
Horizon provides healthcare services to more than three million New Jersey residents, including roughly 750,000 active and retired public employees and their families.