The Maryland Insurance Administration (MIA) has ordered UnitedHealthcare to pay $1.5 million to reimburse hospitals and radiology service providers for health insurance claims.
The MIA said its investigation of utilization review procedures used by UnitedHealthcare and its subsidiaries uncovered the use of non-compliant procedures. The payor agreed to conduct a self-audit and found some claims were inappropriately denied as a result of these non-compliant procedures. In a consent order signed last week, the Minnetonka, Minn.-based UnitedHealthcare agreed to reimburse nearly $930,000 to hospitals and to radiology providers in more than 300 cases and to pay $633,000 in penalties.
"It is our job as regulators to be sure health insurers have fair and timely utilization review procedures in place, as required by State law, to ensure appropriate payment for medical care," said Ralph S. Tyler, Maryland insurance commissioner. "United's full cooperation with our investigation and its self-audit process made it easier to identify erroneously denied claims submitted by hospitals and radiology providers."
Routine required filings by UnitedHealthcare revealed issues with two programs designed to alert the payor when physicians recommended United's members receive elective hospital care or radiology services--the Hospital Notification Program and the Radiology Notification Program. The programs did not meet all the requirements of Maryland law for utilization review programs and thereby placed inappropriate demands on hospitals and physicians referring patients for radiology services.
UnitedHealthcare's self-audit of the hospital program identified 85 cases of inappropriate payment denials of $756,130 in charges. The insurer has agreed to pay the hospital claims associated with these 85 cases. Similarly, UnitedHealthcare's self-audit of the radiology program identified 227 cases of inappropriate payment denials of $172,599 in charges. For both programs, UnitedHealthcare agreed to pay a penalty of $613,000.
In addition, MIA said that UnitedHealthcare inappropriately required certain providers to submit a Wellness Assessment Form for behavioral health care services reviewed by United Behavioral Health. Maryland state law provides for the use of a uniform treatment plan form and prohibits requirements for providers to use additional forms. UnitedHealthcare's self-audit showed no claims were denied due to the failure to submit the wellness form. For requiring the use of an additional treatment plan form, United agreed to pay a penalty of $20,000.
The regulatory actions were collectively taken against UnitedHealthcare Insurance, UnitedHealthcare of the Mid-Atlantic, MD-Individual Practice Association, MAMSI Life and Health Insurance, Optimum Choice and United Behavioral Health.