Pennsylvania Department of Insurance Discovers Violation Against Geisinger

HARRISBURG, Pennsylvania (WTAJ) – A hospital with multiple medical centers in Pennsylvania has breached a pending medical claim, the Pennsylvania Department of Insurance (PID) has announced.

In a news release issued Wednesday, acting insurance commissioner Michael Humphries said Geisinger’s violations were found during a “comprehensive Affordable Care Act (ACA) market conduct examination.” . According to PID, Geisinger said he was cooperative in trials from January 1, 2015 to March 31, 2016 and from January 1, 2017 to March 31, 2018.

A state investigation found that claims should have been paid, but were in fact denied by vendors of behavioral health services, the release said. Geisinger indicated that from 2016 he made system changes to 2018, including an all-new processing system for medical claims. In 2019, all behavioral issues were handled in-house.

As punishment, Geisinger was ordered by PID to reprocess the erroneous claim and pay the claimant with applicable interest. The report also found unfair insurance practice law violations, including “unclear communication with members, miscalculation of maximum out-of-pocket costs, and incomplete claim files,” the report said. Geisinger must show proof of return and pay a penalty of $125,000.

“The insurance sector’s top priority is consumer protection in the marketplace and these inspections give the sector an opportunity to ensure that businesses are maintaining high standards and that consumers are enjoying their rights.” said Humphreys. “The results of the trial will hopefully lead some consumers to not only receive damages, but also to improve their internal processes.”

About 60,000 Pennsylvanians have been awarded more than $5.8 million in compensation, according to PID. A full copy of the report can be read online at the PID website.

WTAJ reached out to Geisinger for comment but did not immediately respond.