Schneiderman announces settlement with Excellus over excessive copays for customers in Rochester area

New York Attorney General Eric T. Schneiderman today announced an agreement with Excellus Health Plan, Inc. requiring that its contracted health-care providers offer refunds to thousands of members in New York state for charging “excessive” copays.

The attorney general in a news release said his investigation revealed that Excellus issued incorrect “explanations of benefits” documents, which “imposed an additional specialty co-payment for member visits to a primary care provider.”

Excellus, which is headquartered in Rochester, is the largest health insurer in the Central New York, Southern Tier, and Mohawk Valley regions.

The investigation started when an Excellus member in the Rochester area complained to the attorney general’s Health Care Bureau helpline that his provider billed him a specialty care co-payment of $25, after visiting his primary care doctor to whom the patient had already paid the primary care co-payment of $15, the attorney general’s news release stated. The amount billed reflected the amount on the “explanation of benefits” issued by Excellus to the member.

“Many New Yorkers spend a significant portion of their income on health insurance, and it’s critical that their claims are billed and processed correctly,” Schneiderman said in the release. “Patients shouldn’t have to pay for mistakes made by providers and health insurers.”

Schneiderman’s office said that when it inquired about the matter, Excellus acknowledged that it issued the explanations of benefits incorrectly.

“Excellus explained that certain providers affiliated with the University of Rochester Medical Center (URMC) had changed their tax identification numbers without informing Excellus. When the providers’ claims were submitted to Excellus after the tax identification number change, the Excellus claim processing system could not match the claims to the primary care provider and instead defaulted to the higher copayment,” the news release noted.

Excellus has identified 2,973 primary care claims from providers recently affiliated with URMC that Excellus processed as specialty care, which could result in refunds of about $74,000 for consumers, according to the attorney general’s office.

As part of the agreement, Schneiderman’s office said Excellus has completed or committed to do the following:

• Update the URMC provider tax-identification information in its systems, so that primary care claims will be correctly processed and providers will charge only the primary care co-payment when no specialty services are provided;
• Review its claims data to identify each member who saw his/her primary care physician, and was assessed additional co-payments for specialty services;
• Mail letters to affected members explaining that they may have been charged excess co-payments, and setting forth the steps to secure a full refund; and
• Monitor the refund process undertaken by URMC, and obtain from URMC an accounting of all refunds issued.

Assistant Attorney General Carol Hunt of the Health Care Bureau handled this case, according to the release. Lisa Landau, bureau chief, leads the Health Care Bureau. The Health Care Bureau is a part of the Social Justice Division, which is led by Executive Deputy Attorney General Alvin Bragg.