PROVIDENCE – UnitedHealthcare Insurance Co. has been fined $100,000 for failing to cover claims for substance abuse treatment in accordance with state law using guidelines set by the American Society of Addiction Medicine, the R.I. Office of the Health Insurance Commissioner said Wednesday.
The commissioner’s office said a review revealed that the Minnesota-based health insurance carrier failed to honor 67 claims from 2015 through 2018 for services including intensive outpatient treatment programs, inpatient detoxification and day treatment programs after determining they were not medically necessary. The state regulator said it conducts such reviews as part of efforts to increase behavioral health care access and ensure parity between behavioral health care and physical health care services.
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UnitedHealthcare of New England Inc., a subsidiary of UnitedHealthcare Insurance, is the third-largest health insurer in Rhode Island, according to the PBN Book of Lists, with 178,379 people covered as of July 2021.
“Following OHIC’s review, the office determined that coverage criteria for levels of care of substance-use disorder treatment for 2015 through 2018 were materially inconsistent with those set forth by ASAM,” according to a statement from the commissioner’s office. “Moreover, the criteria UnitedHealthcare used were also inconsistent with generally accepted standards of care among substance use treatment providers. This material inconsistency, more likely than not, would have affected coverage decisions for members in a manner resulting in clinically inappropriate coverage decisions.”
Gov. Daniel J. McKee released a statement criticizing UnitedHealthcare for its alleged failure to cover the substance abuse treatment.
“Rhode Island is committed to improving access to behavioral health care and substance use disorder treatment,” McKee said. “Now more than ever, it is critical that our administration hold health care entities accountable for ensuring parity between physical and behavioral health care.”
McKee also commended state regulators for uncovering the problem.
“I thank the Office of the Health Insurance Commissioner for their full review of this matter and for continuing to hold health insurance companies accountable when their practices are not consistent with Rhode Island law,” McKee said. “Rhode Islanders deserve fair and adequate access to the care they need and our Administration will continue to ensure that happens.”
UnitedHealthcare responded on Wednesday afternoon.
“We are committed to supporting the health needs of our members,” said spokesperson Maria Gordon Shydlo. “We worked with the state to address its concerns and continue to enhance processes to better address concerns when they arise. We look forward to collaborating with the state to ensure Rhode Island residents have access to the appropriate care they need to get and stay healthy.”
According to a copy of the nine-page consent agreement and order outlining the violations by UnitedHealthcare, the company did not admit to having violated Rhode Island law. But “to avoid the expense and time-consuming process of formal administrative proceeding or future litigation,” UnitedHealthcare decided to “resolve this matter without further administrative proceedings” by paying the $100,000 fine and filing a corrective action plan outlining a framework to ensure that it meets Rhode Island’s criteria for coverage of substance use disorder treatment in line with the American Society of Addiction Medicine guidelines used by the state.
Updates to include a statement from UnitedHealthcare.
Marc Larocque is a PBN staff writer. Contact him at Larocque@PBN.com. You may also follow him on Twitter @LaRockPBN.
