Geisinger cited for health plans claims violations

Danville-based Geisinger is being asked to take corrective action by the state after receiving citations for a series of violations from 2015 through 2018. 

An Affordable Care Act market conduct examination by the Pennsylvania Insurance Department (PIC) found violations within claims processing primarily involving mental health and substance use disorder services by Geisinger Health Plan and Geisinger Health Options. 

Acting Insurance Commissioner Michael Humphreys said Wednesday the examinations identified violations within claims processing, including claims being denied when they should have been paid.  

These denied claims were largely processed by behavioral health vendors, until 2019, when the company brought all behavioral health operations in-house, Humphreys said. 

“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 Humphreys. “The results of the exam will see some consumers receiving restitution, as well as expected process improvements within the company.” 

 Humphreys said Geisinger was cooperative during the examination, which covers the period from January 1, 2015, to March 31, 2016, and January 1, 2017, to March 31, 2018. A second claims experience period was added because the company indicated that it made several systems changes from 2016 to 2018, including the implementation of a new medical claims processing system. 

Geisinger issued a statement in response to the citation. 

“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. 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 examination also reported additional Unfair Insurance Practices Act violations relating to unclear communications with members, maximum out-of-pocket miscalculations, and incomplete claim files, PID said. 

 In addition, the exam found mental health parity violations, as complete and timely quantitative and nonquantitative treatment limitation (QTL and NQTL) analyses were not available, nor were QTLs and NQTLs applied correctly in some plans. 

Humphrey said Geisinger hired an outside consultant in 2019 to help address mental health parity. 

The department has ordered Geisinger to take corrective action to address the violations. Claims that were incorrectly processed must be reprocessed and accurately paid with applicable interest.  

PID said the company must adjust internal controls to address required claims notifications, accuracy and clarity in its communications with members, and oversight of producer appointments and terminations. 

The company must also reprocess all claims for which incorrect visit limits or cost-sharing were applied and provide restitution to policyholders that were required to pay more than that policy allowed. The company must provide proof of payment, including applicable interest, to the department as claims are reprocessed.  

Geisinger is ordered to pay a $125,000 penalty. 

 To date, approximately 60,000 Pennsylvanian consumers have received $5.87 million in restitution as a result of the department’s ACA market conduct examinations of other major health insurers. 

 The department said it will continue to monitor and verify that Geisinger’s corrective actions have taken place, including through quarterly reporting, as well as through a reexamination process in the future.