8/30/2023 0 Comments Horizon direct access design 10![]() Debbra Keegan, a reproductive endocrinologist with the Institute for Reproductive Medicine and Science at Saint Barnabas. The results showed abnormalities, and the Harkels were referred to Dr. And Deanna miscarried again, prompting them to test the fetus for chromosomal abnormalities, the most common explanation for miscarriages. "The nurse had her poker face and Deanna said, 'Do you see anything?' And she said, 'We’ll have to wait for the doctor,' and we were, like, all right this is a problem.” "We went for the first ultrasound, we were expecting the whole (to do), you print out the picture and all that stuff," Jon Harkel said. The Harkels had little trouble getting pregnant, but during a doctor's visit, the nurse became strangely quiet. MORE: Designer baby? NJ lab closer to making science fiction reality MORE: Paid sick leave underway in New Jersey They began their careers, bought a house and decided two years ago that the time was right to start a family, even as they took on extra work to make ends meet. They met when they were students at the College of New Jersey in Ewing and got married five years ago. Jon works in the communications office at a New York college. Deanna is director of donor relations for a private school. The Harkels, both 31, live in Hightstown. The Harkels were grateful for the state's appeals process.īut they said they could have been spared some pain if their request for coverage had been approved right off the bat.Īs it was, they endured a fourth miscarriage, sleepless nights, countless blood tests and a drive to Horizon's headquarters in Newark to make what was ultimately an unsuccessful plea in front of the insurer's appeals board. "The reason for the recent surge is likely due to provider and consumer awareness of the right to appeal," a Banking and Insurance Department spokesman said. Nearly 54 percent of the appeals were overturned the first six months of 2018 60 percent were overturned during that period in 2017 51 percent in 2016, the data shows.īy comparison, about a third of the 136 appeals during the first six months of 2008 were overturned, according to the state. State officials noted it is a tiny fraction of overall claims, given that more than 3 million New Jerseyans are covered by plans that are overseen by the program.īut when consumers appeal, they very often prevail. Insurers' decisions, however, are getting challenged more often.įrom January to July 2018, 1,151 consumers appealed their insurance denials, up 110 percent from the same period in 2017 and more than 200 percent from the same period in 2016, according to state data. ![]() Horizon in a statement Thursday said it relies on medical and scientific research to "ensure that no matter how complex medical conditions or procedures may be, our coverage provides for the most appropriate and safest care, based on the best and most current clinical evidence available." ![]() ![]() MORE: Blame brand name drugs for rising health costs, Horizon saysĬonsumers are increasingly taking the fight to the state's Independent Health Care Appeals Program, an appeals process that has been available to many New Jersey consumers since 1997 but has rarely been used. MORE: Can Asbury tech firm help new moms steer clear of opioids? "The consumer can sometimes be put in the middle of that and can be forced to make phone calls back and forth, which just adds stress to the consumer’s health care experience, which is really unnecessary," said Theresa Edelstein, a vice president at the New Jersey Hospital Association, a trade group. And it could intensify as new, costly breakthroughs become available.īut as the Harkels show, the process is emotionally draining, forcing them to find time to take off from work, plead their case in front of Horizon's insurance board and lose sleep. They are jumping into a fray between doctors and insurers over what constitutes medically necessary treatment. It's a sign, state officials said, that consumers are more aware of the option and are more aggressively fighting back. And they are finding success. More than half of the insurers' denials in recent years that have gone to appeal have been overturned. The Harkels are among an increasing number of New Jerseyans who are appealing their insurance denials with the state Department of Banking and Insurance. "It's been so many years of such bad news continually, I was pretty shocked," Deanna Harkel said. Watch Video: NJ couple fights Horizon in bid to have a babyĪfter four miscarriages and denials from Horizon Blue Cross Blue Shield of New Jersey to cover fertility treatments, Deanna and Jon Harkel braced themselves for more disappointment.īut when they read through the letter from the doctor who reviewed their appeal of the insurance denial, they were heartened. ![]()
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