Florida fines more HMOs

Specialties Case Management


Florida fines more HMOs

over ER payment problems

Three more Florida health insurers have been fined a total of $134,000 as the state continues a sweeping investigation of the HMO industry's payment practices for emergency room claims.

Sanctioned in this latest round for improperly paying private and Medicaid claims: Foundation Health, A Florida Health Plan Inc.; Neighborhood Health Partnership; and St. Augustine Health Care Inc.

The investigation is a joint effort of the Florida Department of Insurance and the state's Agency for Health Care Access (AHCA). Their suspicions were aroused in early 1999 in the wake of numerous concerns raised by ER doctors and patients that HMOs were not reimbursing them for claims or were illegally delaying payments.

Investigators studied claims paid over several months in mid-1998 and found hundreds of cases in which claims for patients who had sought treatment in emergency rooms were being mishandled by their insurance companies. Under Florida law, health plans cannot deny a claim for services that were necessary to determine whether a patient was experiencing an emergency, even if the doctor later determines the problem was not an emergency. They must also pay claims within 35 days of receipt and pay predetermined fees for Medicaid claims.

Since the investigation began, AHCA has audited all 35 HMOs in the state and has now issued reports on nine of those. Only one company had a clean record: HealthEase Health Plan.

The companies that were sanctioned must reprocess their illegal ER claims and issue a detailed plan to ACHA outlining how they will correct the problems that led to the mistakes. The "corrective-action plan" must include provisions for staff training and an internal monitoring process to ensure compliance with state law.

St. Augustine was handed the highest fine: $135,000. That amount, however, was reduced to $100,000 in accordance with state law limiting fines for such claims-payment infractions.

The insurance department had expected to begin issuing its own investigative reports in early September, but those have been temporarily delayed, a spokeswoman says.

The culprits so far

Of the 35 Florida HMOs under investigation for possible wrongdoing over claims payments, eight companies have been sanctioned so far. The latest round fined:

Foundation Health, A Florida Health Plan Inc.

Rejected at least one commercial (private) ER claim based on the lack of patient information

Delayed reimbursement on at least 29 Medicaid claims for noncontract health care providers

Reimbursed at least 19 noncontract providers at the wrong Medicaid fee-for-service rate

Total sanction: $24,500.

Neighborhood Health Partnership

Rejected at least four ER claims based on the lack of patient information

Delayed at least 10 Medicaid claims for noncontract providers

Reimbursed five noncontract providers at the wrong Medicaid rate

Total sanction: $9,500.

St. Augustine Health Care Inc.

Delayed at least 192 Medicaid claims

Did not pay at least 75 claims for noncontracted providers at the proper Medicaid rate

Failed to pay the full amount owed to certain providers; reimbursement was made only for a "triage" fee and not other related treatment and hospital costs

Total sanction: $100,000.

Insurers previously fined:

Florida 1st Health Plans Inc.

Humana Inc.

Physicians Healthcare Plans Inc.

Preferred Medical Plan Inc.

Well Care HMO Inc.

If you have a concern about your HMO, call the Florida HMO hotline at (800) 226-1062.

Last updated Sept. 22, 1999

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