California Regulator Slams PacifiCare for Alleged Massive Claims Violations

California regulators have assessed a record $3.5 million fine and are seeking up to $1.3 billion in penalties against a UnitedHealth Group Inc. unit for allegedly violating state regulations governing claims payments.

California Insurance Commissioner Steve Poizner has launched an enforcement action against UnitedHealth’s PacifiCare unit in response to market conduct examinations that identified 130,000 alleged violations in the company’s handling of claims and provider data.

Each violation has a statutory penalty up to $5,000 for a non-willful violation and up to $10,000 for a willful violation—meaning that if all the violations are shown to be willful, the penalty could be as high as $1.3 billion.

The California Department of Managed Health Care assessed a $3.5 million fine, which it said is a state record, and outlined steps PacifiCare must take to correct the claims payment problems, including an independent monitor to oversee changes and additional staff.

PacifiCare is accused of numerous violations, including: wrongful denial of covered claims, incorrect payment of claims, lost documents including certificates of creditable coverage and medical records, failure to timely acknowledge receipt of claims, multiple requests for documentation that was previously provided, failure to address all issues and respond timely to member appeals and provider disputes, and failure to manage provider network contracts and resolve provider disputes.

The two regulatory organizations launched a joint investigation last year after receiving hundreds of consumer and provider complaints about claims payment problems by PacifiCare, particularly after its December 2005 acquisition by Minnetonka, Minnesota-based UnitedHealth.

In a statement, UnitedHealthcare said the issues were largely administrative- and provider-related and that most have no direct effect on PacifiCare members. The company also attributed some of the issues to a provider network transition that had to be completed six months earlier than anticipated due to the acquisition.

In addition, the company said it has largely resolved processing errors involving point-of-service claims, which were the primary focus on the DMHC examination, and is making good progress on ensuring the timely and accurate resolution of provider disputes.

The company also said it has resolved the majority of the claims payment issues identified by the California Department of Insurance and made systemic changes to help avoid them in the future. It also said it has hired additional staff, including a newly appointed vice president of transactions oversight, to oversee its performance.

Meanwhile, the CDI is considering similar broad reviews of other health insurers, although a spokesman declined to identify any insurers.

Filed by Gloria Gonzalez of Business Insurance, a sister publication of Workforce Management. To comment, e-mail editors@workforce.com.