Causey fines UnitedHealthcare $3.4 million for unfair billing practices

An investigation into unfair billing practices that lasted more than four years led North Carolina Insurance Commissioner Mike Causey to fine UnitedHealthcare of North Carolina Inc. and its affiliate UnitedHealthcare Insurance Co. $3.4 million on Friday.

The fine will be distributed to benefit the public schools, as required under Article IX, Section 7 of the North Carolina Constitution.

UnitedHealthcare also agreed to provide the Department of Insurance (NCDOI) with a corrective action plan to address violations uncovered in the investigation and submit to future compliance examinations. 

NCDOI’s Market Regulation Division began its investigation after the Department’s Consumer Services Division saw a growing trend in complaints from UnitedHealthcare’s members and their providers. A review of the complaints showed that members were being subjected to cost-sharing more than the applicable deductible, copayment, and coinsurance liabilities.

The investigation targeted the insurance company’s handling of member grievances and claims processes involving non-contracted or out-of-network providers and facilities for anesthesia and emergency room services to see if it followed its procedures to protect members from balance billing and comply with North Carolina law.

Balance billing occurs when an out-of-network provider charges more than the insurer allows for an in-network service and tries to collect the excess cost from the member. The investigation found instances where UnitedHealthcare did not follow its procedures to negotiate with providers to hold the member harmless.

Out-of-network anesthesiologists, laboratory services, and emergency room departments mainly provided the services. Anesthesia and laboratory services were often performed in conjunction with procedures and services provided at in-network facilities, where a member received services from an out-of-network provider.

The report said the companies’ failure to have in-network anesthesiology and laboratory providers available at in-network facilities should not affect the member’s benefit level or cost-sharing responsibilities for covered services.

State law also prohibits insurers from imposing cost-sharing for emergency services that differ from the cost-sharing that would have been imposed if the provider had been in-network if a prudent layperson acting reasonably would have believed that a delay would have worsened the emergency or the choice of a provider was beyond the covered person’s control.

The report also found that in several cases, when members filed grievances, UnitedHealthcare upheld its decision without any indication that efforts were made to intervene on behalf of the member to prevent them from being subjected to the difference between the amount billed and the companies’ allowed amount.

“Patients receiving emergency room services certainly don’t have the time or capacity to go through a checklist and make sure all providers attending them are in-network,” Causey said in a press release. “UnitedHealthcare’s practices potentially put unnecessary financial burdens on many North Carolinians. I am happy to see that UnitedHealthcare has agreed to take corrective action.”

While UnitedHealthcare accepted the final report and voluntary settlement agreement, it expressly denied violating any statutes.

The post Causey fines UnitedHealthcare $3.4 million for unfair billing practices first appeared on Carolina Journal.