TRENTON – An appellate court today directed a lower court to determine whether the state Department of Banking and Insurance should have jurisdiction in a case involving Horizon Blue Cross Blue Shield, the N.J. Dental Association, and the issue of overpayments.
The court partially overturned a lower court ruling that had dismissed a complaint against the insurer brought by the association and several dentists.
The case essentially boils down to whether Blue Cross is allowed to recover overpayments mistakenly made to out-of-network dentists.
The insurer argued that it is allowed to get its money back by withholding payment on future claims made by the dentists. The dentists countered that they are innocent third parties.
The dental association wants the court to prevent the insurance company from informing any future ineligible patients for whom overpayments are made that the patients have no responsibility to pay the dentists the amount recouped by defendants.
The appellate court said that in regards to this issue – which would involve modifying explanation of reimbursement forms – the judge in the case must address, among other issues, whether the Department of Banking has primary jurisdiction.