The New York Department of Financial Services has fines the health insurance carrier Excellus nearly one million dollars for multiple violations of insurance regulations.
Excellus was caught having denied 166 ER claims, and neglected to send Explanation of Benefits (EOB) as required by law, during a market conduct examination from Oct. 10, 2003 to Dec. 31, 2007.
Excellus, based in Rochester, NY, signed a Stipulation order No. 2012-0047-S and paid a fine totaling $995,000.
The insurer had not included EOBs in response to prescription drug claims. (Such EOBs are required by law, even though the insurer paid most of the claims.) It also omitted claims data on required form Schedule H in 2007.
In all, 166 ER claims were denied, and 337,689 cases of failing to explain coverage or benefits or appeal rights. The State has been informed by Excellus that the ER claims have been reimbursed to consumers. Excellus claims that a systems error denied the ER claims by mistake.
Excellus is a Blue Cross/Blue Shield carrier in New York state. Its website carries no mention of the fine on its News page for the Rochester office nor for the corporate heading. The page does mention a new CEO-elect, “earns highest national accreditation for quality”, and making a grant to improve disaster preparedness.
New York State Dept. of Financial Services Stipulation order No. 2012-0047-S, http://www.dfs.ny.gov/about/stip/Excellus_stip_2012-0047-S.pdf
and other industry sources.