Press Release 2010-01 Arizona Department Of Insurance Orders Health Net To Pay $236,500 In Fines And Correct Violations

NEW ADDRESS


Arizona Department of Insurance
100 North 15th Avenue, Suite 261

Phoenix, AZ  85007-2630

Starting July 1, 2020, we will be the
Department of Insurance and Financial Institutions (DIFI).

Media Contact: Erin Klug Public Information Officer 602.364.3471 or [email protected]

For Immediate Release February 11, 2010

PHOENIX - Insurance Director, Christina Urias, announced the results of an examination of Health Net of Arizona, Inc. (HN) and Health Net Life Insurance Company (HNLIC). On February 10, 2010, the Arizona Department of Insurance (ADOI) ordered the companies to pay civil penalties of $83,500 and $153,000, respectively, for insurance law violations that occurred between January 1, 2007 and December 31, 2008. ADOI ordered the companies to take immediate action to correct health care appeals and claims handling violations and healthcare provider grievances.

Arizona law requires healthcare insurance companies to adhere to strict rules and requirements when handling member appeals of insurer claim payment denials and/or healthcare services denials. ADOI cited both insurers for failure to timely inform their members of appeal decisions, timely acknowledge receipt of an appeal, accurately communicate the reason for the appeal decision, or the member’s right to pursue the appeal further.

Arizona law also requires health insurers to establish an internal system for resolving healthcare provider payment disputes and other provider grievances. ADOI’s previous examinations of both insurers revealed that they had failed to comply with Arizona’s provider grievance requirements, but had corrected earlier violations. In this examination, however, the companies’ grievance systems once again failed to meet the statutory requirements, not only by inaccurately categorizing grievances, but, more importantly, by failing to resolve provider grievances within their own established timeframes.

HNLIC’s violations of the Unfair Claims Settlement Practices Act were particularly troubling because they occurred with such frequency so as to signify a general business practice. In more than 80% of the claim files ADOI examined, HNLIC:

  • Denied members’ claims without conducting a reasonable investigation;

  • Failed to promptly provide a reasonable explanation for the basis of its claim denial to

    its members; and,

  • Failed to pay interest on members’ claims that the companies failed to pay on time.

    ”There is one important thing patients can do to assure they receive the benefits they are entitled to receive under their health insurance policies: be proactive, understand and exercise your appeals rights,” said Urias. “Healthcare providers too, can educate themselves about healthcare insurers’ grievance processes and timely pay and grievance law requirements.”

page1image26656

Page 1 of 2

Consumers can learn more by reading the ADOI’s pamphlet entitled “Consumer Guide to Health Care Appeals”: http://www.id.state.az.us/publications/Guide_to_Healthcare_Appeals_09.pdf.

Providers should read the “Timely Pay-Grievances, Health Care Provider Rights”: http://www.id.state.az.us/publications/TimelyPayGrevBrochure-REVISED-Jan09.pdf.

Consumers can also call the ADOI’s Consumer Affairs Division at (602) 364-2499 or (800) 325-2548 (in Arizona, outside Phoenix); healthcare providers can contact the Provider Information line at (602) 364-2394.

 

Period: 
2010
Priority: 
01
Insurers Offering Individual Health Insurance in Arizona

Lists insurance companies that are offering health insurance to individuals and families in Arizona in 2020.  Open enrollment starts November 1st and now runs through December 17th, 2019.  Individuals can start shopping for coverage now at healthcare.gov or cuidadodesalud.gov (Spanish)

Arizona's Surprise Bill Resolution Report for 2019

As shown in the attached report prepared pursuant to A.R.S. § 20-3118(A), the Department of Insurance received 91 requests for dispute resolution in Calendar Year 2019.  Of those, 53 have been resolved or closed, and health plan enrollees saved $41,538 by submitting their surprise bills for resolution.  

Not all health care bills qualify for the surprise bill resolution process.  The Department's Suprise Out-of-network Billing Dispute Resolution website (https://insurance.az.gov/soonbdr, and especially the section entitled, "I got a surprise bill. Can I submit a request for arbitration?") lists conditions when a health care bill may not qualify under Arizona law for the dispute resolution process.  But for those that do, the enrollee will only be responsible for paying the enrollee's cost-sharing amounts (copay, coinsurance and deductible) if the enrollee provides information the Department needs, and participates in an informal settlement teleconference with the health care insurer and the health care provider.

Notice of Proposed Rulemaking - Corporate Governance Annual Disclosure Model Regulation In 2019, the Arizona Legislature adopted the NAIC Corporate Governance Annual Disclosure Model Act at Arizona Revised Statutes (“ARS”) by enacting the Corporate Governance Act at Title 20, Chapter 2, Article 16 (Laws 2019, 1st Reg. Sess., Ch. 180, § 1).   The Department of Insurance (“Department”) seeks to adopt the correlate Corporate Governance Annual Disclosure Model Regulation.  ARS § 20-492.02 allows the Department to adopt rules to carry out the Act upon notice and an opportunity to be heard.  The Legislature has exempted the Department from Title 41, Chapter 6 for one year after the effective date of the Act.  (Laws 2019, 1st Reg. Sess., Ch. 180, § 2.)
Regulatory Bulletin 2020-01

Uninsured and Underinsured Motorist Coverage Offer Form; SB1087