Excellus pays $995,000 state fine

Excellus Health Plan, Inc. has paid a $995,000 fine levied by the state Department of Financial Services (DFS) for incorrectly denying emergency room claims and not explaining coverage to consumers.

Rochester–based Excellus Health Plan committed the infractions between 2003 and 2007. The nonprofit does business as Excellus BlueCross BlueShield, which is Central New York’s largest health insurer, and as Univera Healthcare in Western New York.

The insurer improperly denied 166 emergency room claims over the four year period, according to a DFS news release. It also failed to provide consumers with explanation of benefits statements when it processed more than 337,000 pharmaceutical drug coverage claims during that time, DFS said.

“Ensuring that consumers are able to obtain the health insurance coverage they are entitled to receive, especially in emergency situations, is essential,” DFS Superintendent Benjamin Lawsky said in the release. “Consumers need to understand what their insurance covers, what it doesn’t cover, and how they can challenge an insurer when a claim is denied.”

Excellus has reimbursed consumers for the wrongly denied emergency room claims, DFS said. The health plan denied the claims because of a systems error that occurred during claims processing, after patients had received treatment, according to the department.

The insurer originally covered nearly all of the pharmaceutical claims in question. But its failure to provide explanation of benefits statements violated state law, according to DFS.

“While this fine reflects the serious nature of these violations, I am encouraged by Excellus’ commitment to take corrective actions,” Lawsky said. “The insurer worked with the department to resolve this issue and has committed to improving its performance going forward.”

Excellus has taken steps to correct the violations, Excellus BlueCross BlueShield Vice President of Communications Elizabeth Martin said in an email.

“As the superintendent noted, we’ve been working with the department to address any outstanding issues,” she said. “The health plan, meanwhile, is committed to retaining national recognition for providing high-quality services at lower-than-average costs.”

Contact Seltzer at rseltzer@cnybj.com