Targeted
News Service (Press Releases) December 12, 2018
ALBANY, New York,
Dec. 12 -- The New York State Department of Financial Services issued the
following news release:
* * *
- Aetna Insurance
Company to Pay Fine of $1.95 Million for Missing Deadlines to Make
Pre-Authorizations, Acknowledge and Respond to Member Complaints and
Acknowledge Receipt of Members' Grievances, Among Other Violations
- Oscar Insurance
Company to Pay Fine of $576,950 for Failing to Adhere to Deadlines for
Utilization Reviews, Failing to Include Explanations of Adverse Determination
Notices and Failing to Include Forfeiture Language in Benefit Statements
Financial Services
Superintendent Maria T. Vullo today announced that the Department of Financial
Services (DFS) has signed consent orders with two health insurers totaling more
than $2.5 million for violations of New York Insurance Law. Aetna Health Inc.,
Aetna Health Insurance Company of New York and Aetna Life Insurance Company
will pay a civil penalty of $1,950,000 for violations including the failure to
make prospective determinations, including pre-authorizations, and failure to
acknowledge and respond to members' complaints within required timeframes.
Oscar Insurance Corp. will pay a civil penalty of $576,950 for violations
including the failure to adhere to deadlines for utilization reviews and
failure to include detailed explanations of adverse determination notices.
"Consumers
have the right to know that their insurers will promptly respond to their needs
related to their health care on a timely basis, as required by New York Insurance
Law," said Superintendent Vullo. "These consent orders demonstrate
that DFS will continue to protect New Yorkers and ensure that all insurers obey
the law."
Aetna
A DFS market
conduct examination found that from January 1, 2012 through December 31, 2015,
Aetna failed to do the following, among other violations:
* Make prospective determinations, including pre-authorizations,
within three business days of receipt of all necessary information;
* Acknowledge and respond to members; complaints within the
required time frames
* Acknowledge receipt of a member's grievance within 15 days;
* Make a grievance determination within 30 days;
* Send initial
adverse determination letters to the insured and providers within 30 days;
* Make an appeal
determination within 60 days of all necessary information to conduct an appeal.
The insurer also
failed to provide the insured, the insured's designee or health care provider
in writing of the appeal determination within two business days; in
appropriately applied cost sharing to certain preventive care services; and
inappropriately denied claims related to certain preventive care services.
Under the consent
order announced today, Aetna will make the following corrections among others:
* Review and revise, where necessary, all procedures related to
utilization review, appeals, grievances and complaints to ensure that timely
determinations and notifications are given to insureds, providers, and other
recipients;
* Review and revise all adverse determination letters for external
appeal and timeframe information in compliance with New York Insurance Law and
federal statutes;
* Monitor all
vendors who may perform the services listed above.
Aetna also will
reprocess all preventive care claims where cost sharing was inappropriately
applied and make overdue payments, including interest; and reprocess all claims
that were inappropriately denied, and make overdue payments, including
interest.
Oscar Insurance
Company
A DFS market
conduct examination found that from January 12, 2013 through December 31, 2015,
Oscar Insurance Company violated insurance law as follows:
* Failing to make a determination for prospective utilization
reviews within three business days;
* Failing to make a determination for concurrent utilization
reviews within one business day;
* Failing to include an accurate and detailed explanation of the
clinical rationale for the denials in the adverse determination notices; and
* Failing to include forfeiture language in the explanation of
benefit statements.
Under the consent order announced today, Oscar Insurance will
take action to correct the violations, including but not limited to:
* Revising explanation of benefit statements to include the
appropriate forfeiture language;
* Revising adverse determination notices to include a detailed
explanation of the clinical rationale for denials; and
* Reviewing and
revising all procedures, if necessary, related to utilization review in order
that timely determinations are made.
A copy of the Aetna
consent order can be found here (https://www.dfs.ny.gov/about/ea/ea181212_aetna.pdf).
A copy of the Oscar
Insurance Company consent order can be found here (https://www.dfs.ny.gov/about/ea/ea181212_oscar.pdf).
https://insurancenewsnet.com/oarticle/dfs-fines-two-new-york-licensed-insurers-more-than-2-5-million-for-violations-of-insurance-law?utm_source=Newsletter&utm_medium=email&utm_content=subscriber_id%3A&utm_campaign=HealthNews20181213#.XBJ7PCX4-JA
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