The Rochester-based parent of Univera Healthcare has paid $3.1 million in refunds to consumers and providers after computer problems with its automated claims system a year ago resulted in claims being wrongly denied and members being overbilled.
Excellus BlueCross BlueShield improperly rejected more than 12,000 claims after its computers failed to account for deductibles that had already been paid and met by consumers, according to a statement from New York Attorney General Eric T. Schneiderman announcing an agreement with the company. Excellus owns Univera and is part of Lifetime Healthcare Cos. of Rochester.
As a result, those customers were billed by their providers for costs that should have been covered by insurance. In turn, they overpaid the doctors, or the providers absorbed the losses. Most of those members affected were in high-deductible health plans, where members must first pay out of pocket to satisfy a hefty deductible before the rest of their insurance coverage kicks in.
Excellus has paid out $700,000 to customers who were owed less than $250 each and $2.4 million to customers who were owed more than $250. It has also paid participating providers where appropriate, and the company agreed to reach out to members to ensure that anyone who overpaid providers receive restitution. It will also audit and monitor its claims processing procedures in the future.
"An insurance policy is a two-way street," Schneiderman said in a news release. "New Yorkers who live up to their end of the bargain by paying their premiums and deductibles deserve to have their insurance company live up to its promises by properly paying their claims."
Excellus said the accounting errors resulted from "a technology glitch" after it made some changes to its software, and affected claims processed after Sept. 1, 2011. The computer system simply did not properly add up or account for payments that had already been made toward consumers' deductibles.
The company found the "accumulator" problem after it began getting consumer complaints, which also triggered the state's probe. Excellus has since fixed its claims system.
"From the time we discovered that our computer system was miscalculating some of our members' deductibles, we have worked to make our customers financially whole," said Univera and Excellus spokesman Peter B. Kates. "We apologize for the problems the accumulator issue has caused for our members and providers."
In his news release, Schneiderman called the payments a "settlement … requiring the insurer to refund plan members." But the company said that it had brought the matter to the state's attention in the first place and had already paid out the refunds, with interest. The actual "settlement," or fine, totaled $250,000, Kates said.
Members do not have to take action to receive refunds. The company will mail letters to affected people in early January with claims details and information on obtaining help with anything unresolved.
Consumers with questions also can call the attorney general's Health Care Bureau Helpline at (800) 428-9071.