N.C. Insurance commissioner fni es insurance company and aflfiiate

North Carolina Insurance Commissioner Mike Causey fined United Health Care of North Carolina Inc. and its affiliate United Health Care Insurance Co. $3.4 million following over four years investigating the companies’ claims handling practices involving balance billing.

In addition to the fine United Health Care agreed to provide the Department of Insurance with a corrective action plan to address violations uncovered in the investigation and submit to future compliance examinations. The investigation targeted United Health Care’s handling of member grievances and claims processes involving non-contracted or outof-network providers and facilities for anesthesia services and emergency room services to see if it was following its procedures to protect members from balance billing and complying 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 United Health Care did not follow its own procedures to negotiate with providers to hold the member harmless.

“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 arein-network,”Commissioner Causey said. “United Health Care’s practices potentially put unnecessary financial burdens on many North Carolinians. I am happy to see that United Health Care has agreedtotakecorrectiveaction.”

While United Health Care accepted the final report and vol- untary settlement agreement, it did not admit to the findings contained in the report. It expressly denied violating any statutes, rules or regulations.

The $3.4 million fine will be distributed for the benefit of the public schools as required under Article IX, Section 7 of the North Carolina Constitution.

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

These medically necessary services were mainly provided by out-of-network anesthesiologists, laboratory services and emergency room departments. The an- esthesia 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 companies’ failure to have in-network anesthesiology and laboratory providers available at in-network facilities should not afef ct the member’s benefit level or cost-sharing responsibilities for covered services, the report says.

North Carolina General Statute 58-3-200(d) says, “No insurer shall penalize an insured or subject an insured to the out-ofnetwork benefit levels unless contracting health care providers able to meet health needs of the insured are reasonably available to the insured without unreasonable delay.”

St a- telawalsoprohibitsinsur ers 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 control of the covered person.

The report also found that in a number of cases when members filed grievances, United Health Care 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’allowedamount.

United Health Care 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.”