Health Care Bureau Annual Report 2023-2024

A provider billed a patient’s insurance $63,172 for an MRI with contrast, $59,700 of which was for Glucagon HCl per 1 mg. After their insurance processed the claim, the consumer owed $0 for the MRI, but more than $5,000 for the medication. The consumer contacted the helpline. An OAG advocate discovered that the provider had mistakenly billed for 150 units of medication instead of one single unit. The advocate followed up. Further investigation determined that the overbilling had also happened with other consumers, as far back as 2017. The provider indicated that they had incorrectly billed insurance more than $530,000 for 59 other consumers.  Of these other consumers, 14 patients were refunded $3,370 each, while the remaining 44 patients had no change in patient responsibility. 

A consumer contacted the helpline when she received a $160 bill after her annual well-woman preventive visit. The OAG determined that the provider had not billed the visit with the appropriate preventive-medicine billing code. The OAG asked the provider to determine if the claims should be resubmitted with preventive diagnosis codes. The provider responded that they had billed the patient correctly. The OAG then contacted the insurance company regarding the appropriate coding under the insurer’s billing guidelines. The insurance company agreed that the provider had billed the preventive visit incorrectly and removed all cost-sharing for the consumer. 

A consumer complained that they had been billed for three appointments that did not take place. In addition, they had been billed for psychotherapy services during two of the appointments, although they did not receive any psychotherapy services during their visits to the provider. The consumer contacted the helpline and OAG was able to obtain a $0 balance statement from the provider.

A consumer contacted the helpline after paying $5,800 up front for his cataract surgery because the insurance company would not reimburse him for the surgery. An OAG advocate contacted the insurance company. The insurance company told OAG that the patient’s ophthalmic provider had indicated the consumer had signed a waiver stating that they understood that the procedure they received would not be covered by insurance. The insurance company asked the ophthalmic provider to provide the waiver, but the provider did not produce a copy of it. The ophthalmic provider issued the consumer a full $5,800 refund.

A consumer was billed $6,018 for laboratory services. His insurance carrier also sent him an explanation of benefits indicating member responsibility was $0. The consumer tried multiple times, without success, to have the lab waive the bill before contacting the helpline. The OAG sent an inquiry to the lab. The lab responded by waiving the bill and sending a letter to the consumer indicating that the patient’s responsibility was $0. 

Upon being admitted to a hospital, a consumer showed documentation that he qualified for financial assistance as an individual experiencing homelessness. The hospital assured him that his care would be 100% covered by financial aid. However, the consumer continued to receive bills for $1,210. He attempted to correspond with the hospital regarding these bills but struggled with a language barrier. After OAG intervened, the hospital confirmed that full financial assistance would be applied to the consumer’s account. The hospital resolved the balance.  
 

A consumer’s insurance company had approved two surgical procedures, including preoperative services, such as testing, office visits, and diagnostic imaging. Although the claims had been approved and paid, the consumer received a bill for $82,000. An OAG advocate wrote to the hospital, pointing out that the services had been preapproved as indicated in the patient’s explanation of benefits. The hospital then corrected the bill. 

Many consumers complained to OAG about receiving bills for emergency department visits after they took a COVID-19 test at certain Northwell Health facilities. The OAG began an investigation and found that Northwell Health deceptively advertised three of its emergency departments as COVID-19 testing locations and then billed consumers for emergency-room visits. This included individuals who took a COVID-19 test at a drive-through testing location. Northwell’s practice involved billing for visiting an emergency room that was initially advertised as a COVID-19 testing location. This unlawful practice violated New York state consumer-protection laws. These laws prohibit deceptive acts or practices in the conduct of business, as well as false advertising. As a result of OAG’s investigation, Northwell Health refunded $400,000 to 2,048 consumers, improved its COVID-19 testing advertising practices, and paid a $650,000 penalty to the state. 

The OAG received many consumer complaints about being billed for COVID-19 vaccinations at Northwell Health-GoHealth Urgent Care clinics. The OAG’s investigation revealed that 731 patients made out-of-pocket payments totaling $14,996 to satisfy vaccine charges. Northwell Health-GoHealth referred 72 unpaid accounts to collection agencies. This was an unlawful practice under the Centers for Disease Control’s (CDC) provider agreement regarding COVID-19 vaccine distribution. This provider agreement required providers to administer the COVID-19 vaccines at no out-of-pocket cost to the consumer. As a result of OAG’s investigation, Northwell Health-GoHealth must disclose and update its billing practices, withdraw accounts sent to collections, reimburse all wrongly charged consumers, and pay a $25,000 penalty. 

This investigation arose from numerous consumer complaints about being unexpectedly billed by CareCube for COVID-19 tests. OAG’s investigation revealed that CareCube improperly charged patients when it was an in-network provider and the test should have been free. As a result of an investigation by OAG, CareCube must retain an auditor to identify all patients who were wrongfully charged so they can be refunded with interest and pay a $300,000 penalty.  

A consumer had paid out of pocket for seven days of rehabilitation services. She later learned that her husband’s Medicare had also paid for the same services. The consumer contacted the facility, which repeatedly assured her she would be receiving a reimbursement check. She never received a check. She contacted the helpline. The OAG inquired about the reimbursement. The facility stated that it had mailed the check. The consumer then confirmed she had received the check. 

A consumer had been unable to use her power wheelchair due to a dead battery. Her plan had approved coverage of a new battery. The durable-medical-equipment vendor supplying the battery did not schedule a delivery. Instead, the vendor asked the consumer to travel to their office for the battery installation — which she physically could not do. The consumer contacted the helpline. An OAG advocate was able to intervene and schedule a battery delivery and installation for the following week. 

The helpline resolved the issue with no out-of-pocket cost. A consumer was balance-billed $1,100 by an out-of-network physician for an emergency room visit years earlier. The provider brought the consumer to court over the outstanding bill. The consumer told the helpline that his insurance company had said that he was responsible only for his $100 copay. The insurance company told him that the hospital had been paid. It turned out that the entity sending the bill was not the one that the insurance company had paid. As a result, the bill had gone ignored. An OAG advocate reviewed the insurance policy for protections against surprise billing. The insurance company sent the consumer a check for the full balance, so he could pay the provider with no out-of-pocket cost; and the court action was dismissed. 

An insurance plan approved a prior authorization for a consumer’s new prosthetic leg. After the device was made, the insurance company denied 17 of 18 codes, asking for more documentation. The provider appealed the denial and resent documentation, but the consumer received no response to the appeal. The OAG inquired into the matter. The insurance plan admitted that the appeal had not been handled appropriately and overturned the denial. The consumer finally received his new prosthetic leg. The insurance plan also paid him prompt-payment interest, which is interest due because the payment was made and the device was delivered late. 

A consumer was billed $125 that he had already paid to a laboratory by check. He contacted the lab multiple times about the issue and sent a copy of the cashed check from his bank. Despite his documentation, the lab continued to bill him. The lab eventually sent the balance  to a debt collector. After OAG involvement, the lab located the payment, applied it to the consumer’s account, and withdrew the balance from collection.

A consumer complained because her health plan would not cover the removal of an abnormality during her preventive colonoscopy. The health plan claimed that the removal procedure was not part of preventive care or screening. The health plan denied coverage both initially and on appeal. The OAG became involved and asked the health plan to review regulatory guidance regarding insurance coverage for the prevention of colorectal cancer. The health plan reprocessed the claim, made additional payments to the provider, and removed cost-sharing for the consumer.

In 2008, a consumer had a work-related injury resulting in low back pain.  His treatment had been paid by workers’compensation insurance until his claim was settled in 2012. He later had procedures to a different part of his spine that were unrelated to the original workers’ compensation injury. However, the provider doing these procedures continued to bill his workers’ compensation insurer for an additional 75 claims. The consumer contacted the helpline. After confirming that the additional procedures were unrelated, the consumer’s private insurance company processed the 75 claims in dispute. After OAG resolved the issue, the consumer owed coinsurance of only $372. Between the amount that was contractually reduced for in-network providers and the amount the insurance company paid, the consumer saved $249,339. 

The helpline received a complaint regarding the denial of coverage for an oral contraceptive under UnitedHealthcare’s Oxford plan. The OAG launched an investigation that uncovered that UnitedHealthcare required patients to take certain actions before obtaining birth control. These actions included prior authorization or step therapy, which is a process that requires patients to try alternative treatments. This requirement is unlawful under New York’s Comprehensive Contraceptive Coverage Act (CCCA). The CCCA requires health insurance plans to cover FDA-approved contraceptives without copays, restrictions, or delays. As a result of the investigation, UnitedHealthcare agreed to train all claims-approval staff on the law; reimburse all out-of-pocket costs plus interest to its members who overpaid for birth control; and ensure that all of its health plans are covering contraception without copays, restrictions, or delays. In addition, UnitedHealthcare is paying a penalty of $1 million.  

A consumer with metastatic melanoma required a CT scan. The consumer’s health plan denied coverage of the scan because its medical-necessity guidelines allow only one CT scan every 12 months. However, the consumer’s oncologists stated that the current guidelines recommend a CT scan every six to 12 months. After an OAG advocate wrote to the health plan, the denial was overturned. The plan approved preauthorization of the CT scan. 

A consumer went to the emergency room after being advised to do so by her urgent care doctor and her health plan’s own telemedicine provider. She was admitted to the closest hospital and underwent emergency surgery. Her insurance denied coverage. In its denial letter and explanation of benefits, the insurance company stated that the consumer owed $0. However, the hospital was outside the health plan’s network and not obligated to obey the health plan’s $0 patient responsibility. The health plan’s denial letter also indicated surgery was medically necessary ─ but at an outpatient level of care rather than at an inpatient level. The consumer was not able to control the level of care that she received. The OAG wrote to both the hospital and insurance plan and asked them to work together to facilitate a resolution. The health plan reached out to the hospital and submitted corrected claims. Discussions continued between the hospital and health plan. The health plan agreed to reprocess the claims. The hospital agreed to not balance-bill the consumer, who saved $49,189. 

In a molar pregnancy, a fertilized egg develops into a nonviable mass of tissue rather than a fetus. A consumer required the removal of abnormal tissue from her uterus through dilation and evacuation ─ that is, an abortion procedure. The procedure was necessary to prevent serious complications, including cancer. Her health plan denied initial coverage and two subsequent appeals. This was because the plan covered abortion only where “carrying the fetus to full term would seriously endanger the life of the mother.” In this consumer’s case, the abnormal tissue was not a fetus and would not develop into a fetus. Her doctor had determined that it was medically necessary to remove the tissue to prevent serious health risks. After OAG intervened, the health plan reprocessed and paid the claims with no cost-sharing for the consumer. 

A health plan denied a patient’s out-of-network residential mental health treatment as a noncovered service. The patient’s family paid more than $43,000 out of pocket for the patient’s care.  The OAG advocate wrote to the health plan regarding the denial and requested the full policy, pointing out that under the contract, the treatment should have been covered. As a result, an agreement was reached with the provider and the claims were paid. 

A consumer had paid for COBRA coverage prior to her employer-provided insurance coverage ending; however, her coverage remained inactive over one month later, when she contacted the helpline. After the OAG inquired, the health plan advised that her COBRA coverage had been terminated due to an employer error. The health plan agreed to create a new backdated policy to avoid any lapse in coverage. 

A consumer obtained new health care coverage and paid the monthly premium in full but had not yet received ID cards for the plan. When she attempted to pick up her prescriptions, she was told to pay the uninsured out-of-pocket amount for her medications. Before contacting the helpline, she had contacted the insurer and received new member ID cards However, she appeared not to have insurance. An OAG advocate reached out to the insurer, who confirmed it had resolved an issue with the consumer’s group number. The pharmacy advised it would reimburse the consumer for any prescriptions paid out of pocket.  

A consumer purchased what he thought was health insurance. Someone had contacted him after he provided information to what he thought was the New York State Health Marketplace website. A person had called him and identified himself as an authorized agent for the state marketplace. When the consumer tried to use the plan for a physical, he learned that he had a worthless wellness plan. The consumer cancelled the plan and contacted the administrator for a refund. He later received a bill from the provider for his physical. The consumer contacted the helpline. Following many efforts by an OAG advocate, the company reimbursed the consumer four months’ worth of premium payments, totaling $1,174, plus $186 to pay his physician bill in full. 

A consumer who was a cancer patient was terminated from his job. In its termination letter, his employer stated that his health insurance would expire at the end of the month. Thinking he still had insurance, he continued to receive care through the end of the month. However, the broker who handled his employer’s insurance benefits notified the insurance company that the coverage had terminated on the date the consumer was let go from his job. The plan denied coverage of the services. The consumer was not able to get the coverage restored and contacted the helpline. An OAG advocate explained to the health plan that the consumer had undergone the medical services in good faith. The consumer had a letter from his employer stating that his coverage would not expire until the last day of the month. It was not the consumer’s fault that the broker had given the plan the wrong date of termination. The insurance company responded, agreeing to restore coverage for the remaining portion of the month. The insurer processed the claims, and consumer saved $10,947 in medical bills.  

A consumer was due for immune globulin intravenous (IVIg) treatment for MS in a few days. Her three earlier claims for the IVlg treatment had been denied, despite having received prior authorization. Her provider would not purchase the $5,000 medication without first being reimbursed for the three prior treatments, totaling $15,000. The provider also sought a confirmation of preauthorization approval for another year. After OAG involvement, the plan confirmed approval of continuing IVlg treatment. The insurance company agreed to reprocess the incorrectly denied claims.   

A consumer had been denied prior authorization for his insulin medication. Insurance representatives informed him that the information provided by his physician did not meet standards of coverage. An OAG advocate wrote to the insurance company and asked them to reach out to the provider for the necessary information. The insurance did so and approved a one-month authorization so the consumer could access the medication while the review was ongoing. The insurer then approved further coverage of the medication. 

A consumer was told she had to pay for her fertility medications up front while the authorization process was taking place. Her plan told her that, once the prescription was approved, she could submit a claim for reimbursement. She used the pharmacy her plan told her to use. Her insurance extended its prior authorization for that specific pharmacy to retroactively include the date she obtained the medications. But, when the consumer submitted her claim, her insurance denied it, saying it would not cover out-of-network pharmacy claims. An OAG advocate wrote to the insurance company’s pharmacy benefit manager. They responded that a full refund of $3,675 had been issued to the consumer.