The Geisinger Health Plan has denied health insurance claims for what should have been covered. According to state insurance departments, many of the unjustified denials concerned mental health care and substance abuse treatment.
The problem was discovered during routine federally-required audits.
The insurance department is asking Geisinger Health Plan to reprocess claims and reimburse customers for incorrectly denied claims, including interest.
In addition to requiring Geisinger to correct the issues that caused the error, the insurance department fined Geisinger $125,000.
“The insurance sector’s top priority is consumer protection in the marketplace and these inspections give the sector an opportunity to ensure that businesses maintain high standards and that consumers enjoy their rights. Insurance Commissioner, said in a news release.
“The results of the trial will not only allow some consumers to receive compensation, but also to improve their internal processes.”
In a written statement, Geisinger Health Plan said it was “in the process of identifying next steps with the insurance department, but many of the issues identified during the investigation have long been addressed or fixed.”
According to Geisinger, the review included interviews with about 70,000 people.
“We appreciate the opportunity to partner with the insurance sector and see opportunities for improvement. This is very much in line with Geisinger’s mission to make health easier for the communities we serve. We are doing it,” says Geisinger.
The insurance department said it was unclear how many Geisinger members were affected by the breach or the total amount of claims wrongfully denied.
“Geisinger reports on reimbursements as part of its quarterly reporting to the department. and members may take time to identify,” the ministry said in an email to the question.
This exam primarily covers claims made between January 1, 2015 and March 31, 2016 and January 1, 2017 and March 31, 2018.
The insurance department also said it had found issues with unclear communication with customers, including incorrect calculations related to maximum copayments. A violation of the Mental Health Equality Act, which requires treatment like a claim, was also found.
The department noted that some of the falsely denied claims related to mental health and substance abuse were handled by behavioral health vendors before Geisinger brought the process in-house in 2019.
Additionally, Geisinger noted that in 2019 it hired an outside consultant to ensure equality in mental health.
Since 2018, 60,000 Pennsylvania consumers have received $5.87 million in compensation after similar investigations by health insurers, according to the agency.
These numbers do not include recent Geisinger Health Plan violations. or recent breaches related to the Capital Blue Cross, the department said.
Details from Pen Live:
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