From staff reports
The state has handed UPMC Health Coverage Inc. and UPMC Health Options Inc. a $250,000 penalty stemming from a comprehensive Affordable Care Act market conduct examination of practices and procedures.
The Pennsylvania Insurance Department (PID) examination of UPMC, which covers Jan. 1, 2015, through March 31, 2016, identified claims processing violations, including claims being denied when they should have been paid and notification and processing delays, according to a PID news release.
The examination also reported Unfair Insurance Practices Act violations relating to unclear communications, as well as prompt pay and interest violations, and maximum-out-of-pocket miscalculations, the release said.
According to the release, PID has ordered UPMC to take corrective action to address the violations. Claims that were incorrectly processed under the prompt pay law must be reprocessed and accurately paid with applicable interest.
UPMC also must reprocess all claims for which incorrect cost-sharing was applied, and proof of payment, including applicable interest, must be provided to PID, according to the release.
Finally, the release said, UPMC must enact enhanced processes and system improvements for maximum-out-of-pocket calculations. The department may verify that these corrective actions have taken place through a re-examination process.
“We work to ensure that consumers are afforded all the rights and protections guaranteed to them by Pennsylvania law, and these market conduct examinations are a useful tool in that effort,” PID Commissioner Jessica Altman said. “UPMC has been extremely cooperative and thorough in its response to examiner findings.”
