Slide 1 New York State Insurance Department Press Release, September 6, 2007 www.ins.state.ny.us/press/2007/p0709061.htm If you need a copy of the Regulatory Settlement Agreement, please call the Office of General Counsel of MSSNY.. . Slide 2United HealthCare will pay New York $4 million to
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1. IN THE MATTER OF THE UNITEDHEALTHCARE INSURANCE COMPANY, ET AL. REGULATORY SETTLEMENT AGREEMENT
2. Slide 1 New York State Insurance Department Press Release, September 6, 2007 www.ins.state.ny.us/press/2007/p0709061.htm If you need a copy of the Regulatory Settlement Agreement, please call the Office of General Counsel of MSSNY.
3. Slide 2
United HealthCare will pay New York $4 million to settle claims processing problems, the largest ever health related settlement entered into by the State Insurance Department, Superintendent Eric Dinallo announced today. This is part of a landmark settlement agreement between the health insurer and 37 states that includes a potential for payments of $20 million and a three-year process improvement plan for United. More than $13 million will be distributed immediately to the participating states.
4. Slide 3 The Settlement follows nationwide complaints and coordinated investigations by numerous state insurance regulators of United HealthCare’s claims practices involving coordination of benefits, appeals and grievances, explanations of benefits, utilization review and other areas.
5. Slide 4
Insurance regulators in the states involved worked jointly under the auspices of the National Association of Insurance Commissioners to achieve the settlement, which covers 26 United HealthCare affiliated insurers and HMOs.
6. Slide 5
The settlement includes a national improvement plan in effect through December 31, 2010. It requires collaborative monitoring of United’s market practices under the direction of the five lead states: New York, Iowa, Florida, Connecticut and Arkansas. The plan establishes benchmarks for improvements to claims accuracy, claims timeliness, appeals review and consumer complaint handling.
7. Slide 6 Failure to meet those benchmarks could result in up to $20 million in additional penalties to United. Any continuing systemic problems discovered by United’s own internal review or via annual collaborative reviews by an independent auditor under the supervision of the lead states would result in restitution to claimants.
8. Slide 7
The Regulatory Settlement Agreement was entered on August 27, 2007 (“Execution Date”) by United HealthCare Insurance Company and its Affiliates.
9. Slide 8 The “Lead Regulators”:
Commissioner of the Arkansas Department of Insurance
Commissioner of the Connecticut Insurance Department
Commissioner of the Florida Office of Insurance Regulation
Commissioner of the Iowa Insurance Division
Superintendent of the New York State Insurance Department
10. Slide 9 The Multi-State Areas of Review:
The Lead Regulators have identified certain areas of concern that the UHC Companies have agreed should be subject to review. (See Exhibit A of the Agreement).
Will commence on Effective Date, August 27, 2007, and end on December 31, 2010 (the “Term”).
After the Effective Date, a Signatory Regulator may seek to add an additional area of review by bringing it to the attention of the Lead Regulators.
The Lead Regulators, in consultation with and the agreement of the UHC Companies, may add the additional areas of review to the Multi-State Area of Review.
11. Slide 10 Multi-State Areas of Review (See Exhibit A):
Coordination of Benefits
Appeals Grievances and Complaints
Explanation of Benefits
12. Slide 11 Exhibit A
Claims: The UHC Companies shall ensure that claims are investigated and paid, denied or contested within the required timeframes, that claims are paid correctly and interest is paid when required, that payments are made at the correct rate, that providers and covered persons are given an opportunity to provide missing information that is needed to process claims before closing claims, that claim files contain all necessary documentation, that explanatory information provided to insured, enrollees, and providers is accurate and complete and contains all required information and that claims personnel shall be properly trained in these duties.
Questions: What criteria will be used to determine whether claims were “paid correctly”? E.G., What coding rules will be applied?
Will doctors have an opportunity to contest past claim payments?
13. Slide 12 Agreement covers “Commercial Insurance”.
Commercial Insurance means all medical insurance policies and health benefit plans issued by UHC Companies and administered on the UHC Platform (as defined by paragraph A.29).
Commercial Insurance does not cover Medicare, Medicaid or any self-funded products or services. Services delegated to and performed by the UHC Companies’ affiliates for Commercial Insurance as third party administrators are within the scope of the Agreement.
14. Slide 13 Process Improvement Plan
(See Exhibit C)
Implementation within 60 days of the Effective Date.
To Monitor Multi-State Areas of Review.
15. Slide 14 Compliance with the Process Improvement Plan will be measured against Benchmarks, (See Exhibit D).
Compliance with the Benchmarks must be achieved on or before the expiration date of the Term.
Exhibit D establishes “tolerance levels. ( UHC Companies will be deemed to be in compliance with the benchmarks if performance falls within the tolerance levels).
16. Slide 15 Restitution Required Under Paragraph C.3
“UHC Companies must make RESTITUTION to its past or present insureds and providers in the ordinary course of business through the reprocessing of identified erroneous claims resulting from installation of provider contracts, fee schedules, eligibility files, and product and case installation, and other claim processing errors.”
Questions: What is meant by “in the ordinary course of business? Do we trust UHC to look for its own errors? What is “any other claim processing errors” Coding Rules? Global Periods? Downcoding?
17. Slide 16 “Additionally, through the implementation of the Process Improvement Plan, where the UHC Companies or Lead Regulators determine that less than appropriate claim payments were made for specific valid claims, the UHC Companies agree to make restitution and make all other appropriate adjustments on such claims, including the payment of interest as required by the laws of the Signatory Regulators, within a reasonable time after making such determination.”
Participating state regulators may alert Lead Regulators regarding systemic problems.
It is important for physicians to complain to state insurance department. Even if the state is not a Lead Regulator the state insurance department can forward complaint to the Lead Regulators.
REMINDER: Lead Regulators may require UHC to make restitution for systemic errors going back to the date of the systemic error, up to 36 months. It is vitally important for physicians to report errors to regulatory agencies.
18. Slide 17
“In the event the UHC Companies or Lead Regulators determine that less than appropriate claim payments were made for valid claims on a systemic basis due to an identifiable error in the UHC Platform (a “System Error”) which resulted in a failure by the UHC Companies to be in compliance with the benchmarks applicable to claim payment standards, the UHC Companies agree to conduct an external review and to make restitution and all other appropriate adjustments on such claims, including the payment of interest as required by the applicable laws of the Signatory Regulators, within a reasonable time after making such determination.”
19. Slide 18 Questions regarding Restitution?
The Restitution language lacks specifics.
What criteria will be used to determine whether claims were appropriately paid?
Can we get details/clarifications from Lead Regulators?
20. Slide 19
The Lead Regulators on behalf of and for benefit of the Participating Regulators will monitor the UHC Companies’ Compliance with the Agreement.
21. Slide 20 UHC Companies agree to retain an independent examiner to assist the Lead Regulators in monitoring the Agreement.
The Examiner will:
Conduct 3 annual compliance reviews;
Prepare written reports;
Review UHC Companies’ progress in implementing the Process Improvement Plan;
Access accuracy and validity of UHC Companies’ quarterly reports.
22. Slide 21
Costs of the Examine will be the responsibility of UHC Companies.
Selection of the Examiner will be subject to the approval of the Lead Regulators.
23. Slide 22 See Paragraph C.7
“The monitoring of the UHC Companies for compliance with this Agreement constitutes an ongoing investigation by the State of Iowa, as a Lead Regulator, pursuant to Iowa Code §505.8. To the extent permitted by law, the work papers, recorded information, and documents produced by, obtained by, or disclosed to the Signatory Regulators shall be given confidential treatment and shall not be subject to subpoena and may not be made public by the Signatory Regulators or to any other person, and shall not be public records subject to disclosure pursuant to other Iowa Law”.
Question: Will anyone be able to monitor the monitoring process?
24. Slide 23
See Paragraphs C.8 and C.9
If UHC Companies are determined not to be in compliance with the Benchmarks, UHC Companies must pay the applicable monetary assessment set forth in Exhibit D.
25. Slide 24
See Paragraph C.10
There may be focus on deficiencies involving compliance in a particular jurisdiction of a Signatory Regulator.
26. Slide 25
What is UHC shielded from? See Paragraph C.11.
For the period of the term and for the 3 calendar years immediately preceding the Effective Date, each of the Signatory Regulators agrees that it will not:
(i) engage in any investigation or examination of activities of UHC Companies relating to the issue subject to this Agreement;
(ii) impose fines, injunction or any other remedy on any of the UHC Companies for any of the matters that are subject matters of this Agreement.
Signatory Regulator may take appropriate action should UHC Companies violate any provision of the insurance laws or regulations outside of the Multi-State Area of Review and not otherwise subject to the Agreement.
27. Slide 26 Which state law applies?
See Paragraph D.5
When an issue applies to multiple jurisdictions the laws of Iowa apply.
When an issue is specific to an individual jurisdiction, the substantive law of that jurisdiction will be utilized.
28. Slide 27 The effectiveness of this Agreement is conditioned upon:
(i) Approval and execution of this Agreement by UHC Companies and Lead Regulators;
(ii) Approval and execution of this Agreement by at least 30 states and whose combined share exceeds 50% of the UHC Companies’ total Commercial Insurance membership.
The date on which the last of these approval is secured will be the Effective Date of the Agreement.
29. Slide 28
To become a party to this Agreement, the Insurance Commissioner must execute the Agreement within 60 days of the Execution Date. The Lead Regulators and UHC Companies may waive the 60 day period.
30. Slide 29
Each Signatory Regulator must give express assurance that this Agreement is enforceable by its terms under the applicable laws, regulations and judicial rulings in its respective jurisdiction.
31. Slide 30
The Agreement may be amended by the Lead Regulators and UHC Companies without the consent of any Participating Regulator, provided that such amendment does not materially alter this Agreement.