The Pennsylvania Insurance Department found that Pittsburgh insurer Highmark Inc. violated rules regarding the payment of claims, as well as rules related to mental health and substance use disorder claims.
The department, which announced the findings this week, was part of a routine examination of all insurers in the commonwealth. It also recently announced fines for Geisinger Health in Danville and Capital Blue Cross in Harrisburg.
Highmark was ordered to pay a $205,000 penalty. It also must reprocess claims that the department found were faulty and pay the amount, plus interest, the department said.
The examination on Highmark covers the period from Jan. 1, 2017, to March 31, 2018.
“Mental health and substance use disorder benefits are critical protections for consumers,” Acting Insurance Commissioner Michael Humphreys said in a statement. “We will continue to be vigilant to ensure that Pennsylvanians are receiving the benefits that they are entitled to, and to be a resource for consumers who are concerned that their mental health and substance use disorder benefits are not being provided in a comparable manner as general medical or surgical benefits.”
The department said it identified violations with refunds related to policy cancellation, claims being denied when they shouldn’t have been and untimely payment of claims.
“The company must adjust internal controls to address required claims notifications, claims processing problems, including timeliness and accuracy of claims payments, accuracy and clarity in its written communications with members, and accuracy of information provided by customer service representatives to members,” the department said. “Highmark must also address effective and timely services provided to consumers with enrollment and billing issues.”
Highmark said it willingly cooperated with the review process.
The Pennsylvania Insurance Department, “however, had concerns with certain operational areas, such as timeliness of claims payment and resolving billing and enrollment issues. As a result, Highmark has paid $205,000 to the Commonwealth in settlement of the review,” the insurer said in a statement.
“The (department’s) conclusions and Highmark’s settlement are consistent with other health plans that had a review completed during the same period of Jan. 1, 2017, through March 31, 2018.”
Geisinger was ordered to pay a $125,000 fine, and Capital Blue Cross must pay an $85,000 fine.
Stephanie Ritenbaugh is a Tribune-Review staff writer. You can contact Stephanie at sritenbaugh@triblive.com.