The Daily Item

Geisinger Health Plan denied some mental health and substance use disorder service claims that should have been paid between 2015 and March 2018.

The Pennsylvania Insurance Department discovered the violations while examining the practices and procedures of the health plan and Geisinger Health Options.

“The Insurance Department’s top priority is consumer protection within the marketplace, and these examinations are an opportunity for the department to ensure that companies are held to high standards and consumers are receiving the benefits to which they are entitled,” said Michael Humphreys, acting state insurance commissioner. “The results of the exam will see some consumers receiving restitution, as well as expected process improvements within the company.”

According to the report from Humphreys’ office, the violations were identified between Jan. 1, 2015, and March 31, 2016, and between Jan. 1, 2017, and March 31, 2018 — the second period was added because Geisinger implemented a new medical claims processing system among several systems changes between 2016 and 2018. The state said Geisinger was cooperative during the examination.

“We appreciate the opportunity to partner with the Insurance Department on opportunities to improve, which is very much aligned with Geisinger’s mission to make better health easier for the communities we serve,” Geisinger said in a statement. “The review period for this most recent Market Conduct Exam dates back as far as January 2015, and we’re pleased to share that the violations cited in the report have either already been remediated or we are in the process of addressing them.”

The Insurance Department’s report said “the examinations identified violations within claims processing, including claims being denied when they should have been paid, primarily involving mental health and substance use disorder services. These denied claims were largely processed by behavioral health vendors, until 2019, when the company brought all behavioral health operations in-house.”

The review also reported violations of the Unfair Insurance Practices Act regarding unclear communications with members, maximum out-of-pocket miscalculations and incomplete file claims. Mental health parity violations were also found. Geisinger hired an outside consultant to address those issues in 2019.

The department ordered Geisinger to take corrective action to address the violations. Claims that were incorrectly processed had to be reprocessed and accurately paid with applicable interest. Internal controls also were to be adjusted “to address required claims notifications, accuracy and clarity in its communications with members, and oversight of producer appointments and terminations,” the report said.

Geisinger was also ordered to pay a $125,000 penalty and to reprocess all claims for which incorrect visit limits or cost-sharing were applied and provide restitution to policyholders who were forced to pay more than the policy allowed.

The department also required Geisinger to provide proof of payment to the state as claims were processed. The full report is available online under the Current Market Conduct Actions section at insurance.pa.gov.

Approximately 60,000 Pennsylvania consumers have received $5.87 million in restitution as a result of the department’s examinations of major health insurers. Consumers who believe their insurance plans are noncompliant, or who have questions about benefits, can contact the state Insurance Department’s consumer services bureau online at insurance.pa.gov or at 1-877-881-6388.

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