Excellus agrees to settlement over screening test denials

The New York State Attorney General’s office has reached a settlement with Rochester–based Excellus BlueCross BlueShield that will require the insurer to issue refunds after it denied claims for childhood lead screenings.

State law requires insurers to cover lead screening for 1-year-old and 2-year-old children. Excellus denied “hundreds” of childhood lead screening claims from August 2009 to September 2011, according to the attorney general’s office.

The insurer also did not cover claims after plan members filed grievances, the investigation found. That left consumers paying for the tests or physicians absorbing the costs.

“Childhood lead screening tests are vital to protect public health, and today’s settlement will ensure that Excellus will follow the law and cover these crucial, routine lead tests for children in our state,” Attorney General Eric Schneiderman said in a news release. “This settlement puts health insurance providers on notice that unlawful denials of mandated insurance coverage will not be tolerated by this office.”

Coding errors in two Excellus claims systems lead to denial of 228 lead screening claims from September 2009 to September 2011, according to Excellus Vice President of Communications Elizabeth Martin. The insurer paid over 99 percent of 53,700 lead screening claims in that time period, Martin said in an e-mail.

“We fully cooperated with the attorney general,” she said. “We identified how the errors occurred and fixed the problems so they can’t be repeated.”

As part of the settlement, Excellus will fix its automated claims systems and refund payments to plan members and providers who paid for childhood lead screenings from 2005 to the present. The refunds will include interest of 12 percent.

The cost of the 228 claims that were denied from 2009 to 2011 was less than $5,000, Martin said. Excellus is still analyzing claims from a period dating back to 2005 and has no estimate for potential refund costs from claims from that time.

Excellus will also create written manuals and hold training sessions about lead screening coverage for employees who analyze claim disputes and grievances. In addition, the insurer agreed to analyze childhood lead screening denials over a six-month period to look for erroneous denials and report its findings to the attorney general’s office.

Finally, Excellus will submit a report to the attorney general’s office detailing the members and providers who receive refunds and undergo an independent audit of its compliance with the settlement.

Excellus is Central New York’s largest health insurer.

Contact Seltzer at rseltzer@cnybj.com