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Post date: July 9 2001

Health Plan To Reimburse For Erroneous E.r. Claims

Attorney General Spitzer today announced an agreement with a major New York health plan, Group Health Incorporated (GHI), to reimburse consumers who erroneously had to pay for emergency room claims that should have been fully covered.

"Unfettered access to emergency room care for those who need it is of critical importance to all New Yorkers," Spitzer said. "This agreement ensures coverage of emergency room claims for those who are entitled to it under the plain terms of GHI's policy."

The Attorney General's inquiry into emergency room claims was prompted by a complaint from a GHI member who was enrolled in the company's "FlexSelect" plan. Under the terms of this plan, GHI members should have been covered in full for emergency care received at any hospital. However, when this individual went to a hospital emergency room while on vacation in Massachusetts, GHI did not pay the claim, but instead applied the bill to the consumer's deductible - and the member erroneously had to pay the entire emergency room bill.

The Attorney General's Health Care Bureau investigated the situation, and found numerous other instances in which emergency room visits were billed to members and GHI failed to fully pay in apparent violation of the terms of the plan.

When this situation was brought to GHI's attention, the health plan acknowledged the problem and took steps to address it, Spitzer said.

Under the terms of the agreement, GHI has reimbursed members for approximately 195 claims totaling almost $35,000. GHI will also pay $5,000 in costs and penalties.

GHI also has agreed to notify its members about the claims errors and make further reimbursements as appropriate. The health plan has also agreed to take steps to ensure that all of GHI's claim processing and member service personnel have implemented the correct payment and coverage procedures for emergency room visits.

The GHI case is the latest in a series of cases in which the Attorney General's office has held health plans accountable under the state's managed care bill of rights. The office previously settled separate cases with HIP, Kaiser Permanente and Vytra for violating the state's ban on prior authorization of claims for emergency services that meet the prudent layperson standard. The office has recently resolved cases in which health plans failed to comply with the information disclosure requirements of the managed care bill of rights by failing to provide copies of their subscriber contract and member handbook to consumers upon request.

GHI, based in New York City, serves approximately 2.6 million people in New York State with a variety of products. Spitzer commended the company for working with his office to resolve the matter.

The GHI case was handled by Health Care Bureau Albany Section Chief Troy Oechsner, and Assistant Attorney General John Powell. Consumers may contact the Health Care Bureau's toll-free hotline at (800) 771-7755 (option #3 on the automated voice menu).