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Post date: January 12 2015

A.G. Schneiderman Announces Settlement With Health Insurer Over Excessive Copays For Customers In Rochester Area

Nearly 3,000 Customers Will Get Refunds, Health Plan Billing Glitches Must Be Resolved

NEW YORK – Attorney General Eric T. Schneiderman today announced an agreement with Excellus Health Plan, Inc. requiring that its contracted health care providers issue refunds to thousands of members in New York State for charging excessive copays. The Attorney General's investigation revealed that Excellus issued incorrect Explanations of Benefits, which imposed an additional specialty co-payment for member visits to a primary care provider.

The investigation began when an Excellus member complained to the Attorney General’s Health Care Bureau Helpline that his provider billed him a specialty care co-payment -- $25 -- after visiting his primary care physician to whom he had already paid the primary care co-payment of $15. 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,” said Attorney General Schneiderman. “Patients shouldn’t have to pay for mistakes made by providers and health insurers.”

When the Attorney General’s office inquired about the matter, Excellus acknowledged that it issued the Explanations of Benefits erroneously. 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.

Excellus has identified a total of 2,973 primary care claims from providers recently affiliated with the URMC that Excellus processed as specialty care, which could result in refunds of approximately $74,000 for consumers.

As part of the agreement, 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. 

Consumers who believe they may have been treated unfairly by a health care provider, HMO or insurance plan, or health-related business should call the Attorney General’s Health Care Helpline at 800-428-9071.

The case was handled by Assistant Attorney General Carol Hunt of the Health Care Bureau. The Health Care Bureau is led by Bureau Chief Lisa Landau. The Health Care Bureau is a part of the Social Justice Division, which is led by Executive Deputy Attorney General Alvin Bragg.