If in-network providers are not available, patients should not face financial penalties from insurance companies to receive out-of-network care, regulators say. Similar protections may apply if the patient is receiving out-of-network emergency services.
This report focused on patients or “members” under UnitedHealthCare coverage in one of the subsidiaries of two companies operating in North Carolina. The exam included a review of a subset of member complaints and claims processed between January 1, 2019 and May 31, 2020.
During the period, UnitedHealthCare received complaints review requests for a total of 1,978 members. Regulators look at 100 random samples to support the initial decision that UnitedHealthCare is allegedly wrong, and find evidence that the Department of Health tried to intervene on behalf of patients facing a balance bill. I found 41 instances that were not there.
Many of these patients mistakenly received from their insurance companies as responsible for all costs associated with the service, regulators say. According to the regulatory report, a “benefit explanation” letter for other patients states:
After reviewing a sample of 100 claims processed, regulators argued many issues, including cases where UnitedHealthcare misinterpreted insurance contract clauses related to appropriate facts or coverage.
For example, regulators said the company was unable to accurately handle out-of-network anesthesia and lab services bills offered at in-network facilities. They also charge cost sharing fees for emergency services outside the network that are different from the cost sharing of emergency services within the network, resulting in a “real or potential balance building bill liability” for the patient, if UnitedHealthcare is Some claimed they had charged cost sharing fees.
