Insurance Commissioner Jessica Altman on Friday announced a $250,000 fine arising from a comprehensive examination of the Affordable Care Act conducted by the Pennsylvania Department of Insurance (PID) on the practices and procedures of UPMC Health Coverage, Inc. and UPMC Health Options, Inc.
UPMC’s examination, covering the period from January 1, 2015 to March 31, 2016, identified claims processing violations, including claims that were denied when they should have been paid and notification and delays in processing. The examination also reported unfair violations of the Code of Insurance Practices regarding unclear communications, as well as immediate wage and benefits violations, and maximum miscalculation. In addition, the examination reported violations of mental health equivalence, where complete and timely quantitative and non-quantitative treatment limit analyzes (QTL and NQTL) were not available, and QTLs and NQTLs were not properly applied.
“Protecting consumers and keeping companies on the highest standards remains a top priority for the insurance department,” Altman said. “We work to ensure that consumers are given all the rights and protections that Pennsylvania law provides to them, and these market behavior tests are a useful tool in this effort. UPMC has been very cooperative and thorough in its response to the examiners’ findings.”
The Insurance Division is responsible for upholding standards of fair business practice for consumers, businesses, and insurance professionals. This work includes researching and resolving consumer complaints, investigating allegations of misconduct from insurance companies, agents, brokers, and others, and ensuring that practicing professionals are properly licensed.
The department has ordered UPMC to take corrective action to address the violations. Claims improperly processed under the Prompt Payment Act must be reprocessed and paid accurately with the applicable interest. The company should also adjust internal controls to deal with punctuality and communication in handling complaints; accuracy and clarity of member communications; Supervising the appointments and termination of producers. UPMC must also reprocess all claims for which incorrect cost sharing has been applied, and proof of payment, including applicable interest, must be submitted to the PID.
Finally, UPMC should enact improved processes and system improvements for out-of-pocket calculations. The Insurance Department may verify that these corrective actions have been taken by a re-examination in the future.
The UPMC ACA exam is the fifth that the department completes. Other companies issued approval orders as follows:
• Blue Cross from Northeastern Pennsylvania to Highmark Corporation.
• United Health Insurance Company
• Istiklal Health Group
Consumers who believe that their insurance plans do not comply with Commonwealth laws or regulations, or who have questions about benefits to which they are entitled, are urged to contact the Insurance Department’s Office of Consumer Services online or at 1-877-881-6388.
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