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Here's what violations a four-year investigation by the N.C. Department of Insurance uncovered and how Greensboro-based UnitedHealthcare of NC will resolve the issues going forward.
UnitedHealthcare will pay a $3.4 million fine after the N.C. Department of Insurance said it found violations of state law in the insurer’s balance billing practices.
N.C. Insurance Commissioner Mike Causey announced on Friday that UnitedHealthcare of North Carolina and its affiliate UnitedHealthcare Insurance have also agreed to provide NCDOI with a corrective action plan and to submit future compliance examinations.
The fine resulted from a four-year investigation into UnitedHealthcare’s claims-handling practices that involve balance billing, particularly for anesthesia, laboratory and emergency room services. Sometimes known as surprise billing, 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 patient.
NCDOI’s investigation found instances where UnitedHealthcare – which has its North Carolina headquarters in Greensboro, led by CEO Anita Bachmann – did not follow its own procedures to negotiate with providers to protect its members from balance billing, the department said. It also found instances where the insurer violated state law.
Although UnitedHealthcare accepted the report and voluntary settlement agreement, the company did not admit to the findings of the report. It expressly denied violating any statutes, rules or regulations, NCDOI said.
UnitedHealthcare told Triad Business Journal on Wednesday afternoon that it was “committed to protecting [its] members from out-of-network care providers who bill excessive fees, particularly in acute or urgent settings.”
“We continue to comply with all state and federal laws, including the federal “No Surprises Act,” which protects members from balance billing,” the insurer said.
NCDOI’s market regulation division began the multi-year investigation after a sustained trend in complaints from UnitedHealthcare’s members that revealed they were being subjected to cost-sharing more than necessary.
Members received medically necessary services were provided by out-of-network anesthesiologists, laboratory services and emergency room departments, NCDOI said. The anesthesia and laboratory services were often performed in conjunction with procedures and services provided at in-network facilities where a patient received services from an out-of-network provider.
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“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.
“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.”
UnitedHealthcare’s failure to have in-network anesthesiology and laboratory providers at in-network facilities should not affect the member’s benefit level or cost-sharing responsibilities, the department said.
Under N.C. General Statute 58-3-200(d), state law prohibits insurers from penalizing or subjecting its members to out-of-network benefit levels, except in cases where members are able to receive care from an in-network provider in a reasonable and timely manner. North Carolina also prevents insurers from imposing cost-sharing for emergency services that differ from the cost-sharing that would have been imposed had the provider been in-network in cases where a delay in care would have worsened the emergency or where a choice of provider was beyond the patient’s control.
The report also found several times where, when members filed grievances, UnitedHealthcare upheld its decision without any indication that efforts were made to intervene and prevent the member from being subjected from the difference of the amount billed and the insurer’s allowed amount.
NCDOI said that UnitedHealthcare would at times respond with an adverse decision letter saying, “You are responsible for all costs related to this service” or “You may be responsible for paying the difference between what the facility or provider billed and what was paid.”
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