The Lead

Pa. Insurance Dept. hits UPMC with $250K penalty for Affordable Care Act violations

By: - January 11, 2022 5:09 pm

One of Pennsylvania’s largest health care providers has been ordered to pay a penalty and take corrective action for Affordable Care Act (ACA) and Unfair Insurance Practices Act violations, according to a release issued by Pennsylvania insurance officials last month. 

UPMC Health Coverage, Inc. and UPMC Health Options, Inc., must pay a $250,000 penalty and take corrective action to address “practice and procedure” violations, the Pennsylvania Insurance Department (PID) found as part of its Affordable Care Act market conduct examination.

The UPMC review, one of five insurance company reviews conducted by PID, and which covered the time period between Jan. 1, 2015, to March 31, 2016, found that, among other violations, the company denied claims that should have been paid, miscalculated maximum out-of-pocket costs, and issued “unclear communications.”

“Protecting consumers and holding businesses to the highest standards remains the Insurance Department’s top priority,” Pennsylvania Insurance Commissioner Jessica Altman said in a statement. “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. UPMC has been extremely cooperative and thorough in its response to examiner findings.”

A statement issued by the department in late December outlined some corrective actions the company must take. 

“Claims that were incorrectly processed under the prompt pay law must be reprocessed and accurately paid with applicable interest. The company must also adjust internal controls to address timeliness and communications in complaint processing; accuracy and clarity in member communications; and oversight of producer appointments and terminations. UPMC must also reprocess all claims for which incorrect cost-sharing was applied, and proof of payment, including applicable interest, must be provided to PID,” state regulators said.

In addition to the monetary penalty and corrective action required by the department to address the violations, UPMC may be subjected to further review to ensure that corrective action has been taken, according to the department. 

“The Insurance Department may verify that these corrective actions have taken place through a reexamination process in the future,” the agency said in its statement.

Denise Hughes, a UPMC Health Plan spokeswoman, told the Capital-Star in an email that UPMC has been already working with the department to address the violations. 

“We thank the Commissioner and her team for the collaborative manner in which the exam was conducted and share the Department’s commitment to ensure that all of our members experience the highest level of quality and service,” she said. “Many of the concerns identified by the Department were corrected even prior to the conclusion of the audit and while we were disappointed to receive even a single violation, we note that our findings are consistent with all of the insurers whose exams have been completed to date.  We have not only incorporated the changes recommended by the Department’s findings but will continue striving to offer the high quality products and services that our members and consumers deserve.”

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