PROVIDENCE – UnitedHealthcare Insurance Co. and UnitedHealthcare of New England Inc. will pay a $350,000 penalty to the state and make a $2.85 million contribution to a mental health fund at the Rhode Island Foundation.
The payments were announced Monday by the state’s Office of the Health Insurance Commissioner.
OHIC’s market conduct examination of the insurer found several violations that potentially delayed or hampered behavioral care for some patients.
A review of 301 behavioral health cases and 183 behavioral health prescriptions from 2014 through 2016 found evidence that UnitedHealthcare applied some coverage exclusions to behavioral health only, and used a stricter benefit review program for behavioral health as opposed to physical health.
Investigators found that certain review criteria used to approve or deny behavioral health services or prescription drugs “were not based on objective, measurable, clinical criteria.” Instead, they relied on “subjective, vague and generalized conclusions or judgment,” according to OHIC.
The insurer’s benefit-review practices violated state law, OHIC said, by hindering patient care. Examples included repeated reviews for services, recommendations for lower levels of care than physicians ordered, and refusing to “adequately consider the patient’s need for continuity and transition of care, and for the patient’s safety and welfare when denying coverage requests,” OHIC said.
Market-conduct exams were also done on coverage of mental health and substance-use- disorder services offered by Blue Cross & Blue Shield of Rhode Island, Neighborhood Health Plan of Rhode Island and Tufts Health Plan.
Violations were found with all three insurers, each of whom made a contribution to the Rhode Island Foundation’s mental health fund.
UnitedHealthcare was the only company that paid a penalty to the state.
