If a state health plan with lawyers, auditors, and subpoena power can get systematically overcharged for their healthcare for years, what's happening to your company?

In this episode of Healthcare Rebuilt, host Boe Hartman welcomes Chris Deacon, former Director of New Jersey's Public Sector Health Plans and author of The Great American Healthcare Heist. Chris shares her journey from being a lawyer to running one of the largest public health plans in America, overseeing healthcare for 820,000 people and $7 billion in taxpayer money.

Chris reveals the alarming discrepancies she discovered when auditing claims processed by Horizon Blue Cross Blue Shield. The state had a "lessor of" provision in their contract; a straightforward protection requiring Horizon to charge whichever was less: what providers billed or Horizon's pre-negotiated rate. Instead, Chris found Horizon was doing the exact opposite. For example, a hospital billed $674,856, but Horizon charged the state over $2 million—a $1.35 million overcharge on a single claim.

When internal complaints were ignored due to political dynamics and industry influence, Chris made the difficult decision to become a whistleblower. Her actions led to a $100 million settlement, though Horizon denies wrongdoing, doesn't have to admit fault, and remains the state's vendor.

This episode serves as a wake-up call for self-insured employers, CFOs, and benefits leaders because if this could happen to a sophisticated government entity, leaders need start asking what's happening at their own company?

In This Episode

• Chris's journey from lawyer to overseeing one of America's largest public health plans.
• The role of Horizon Blue Cross Blue Shield as third-party administrator.
• How the "lessor of" provision was supposed to protect taxpayers.
• Discovering $18 million in overcharges on just 50 claims.
• Why Horizon refused to provide additional claims data.
• The political dynamics that prevented internal resolution.
• Making the decision to become a whistleblower.
• Details of the $100 million settlement (and why it's just a slap on the wrist).
• Why self-insured employers are even more vulnerable than government plans.
• What employers should demand from carriers and TPAs.
• Chris's vision for a more transparent, accountable healthcare system.

Thanks for listening. To learn more about Nomi Health visit https://www.nomihealth.com

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