N.Y. AG changes how Excellus does business

By Bryan Cohen | Mar 16, 2012

NEW YORK (Legal Newsline) - New York Attorney General Eric Schneiderman announced a settlement on Thursday with Excellus BlueCross BlueShield, resolving allegations of the wrongful denial of childhood lead screening tests.

Under the terms of the settlement, Excellus must accurately process claims for routine and necessary tests. Excellus must also fix its allegedly faulty claims system and provide refunds to consumers who paid for lead screening tests out-of-pocket after initially having the coverage denied.

"Childhood lead screening tests are vital to protect public health, and today's settlement will ensure that Excellus will follow the law and cover these crucial, routine lead tests for children in our state," Schneiderman said.

"This settlement puts health insurance providers on notice that unlawful denials of mandated insurance coverage will not be tolerated by this office."

Schneiderman's Health Care Bureau looked into Excellus' alleged denial of childhood lead screening tests after receiving a complaint through its Health Care Bureau Helpline. Schneiderman alleged that Excellus denied hundreds of childhood lead-screening claims over a period starting in August 2009 through September 2011. When plan members filed grievances with Excellus, staff for the company allegedly did not fix the issue. When the insurance claims were denied, physician's offices allegedly either billed the consumers or absorbed the loss themselves.

State law in New York requires insurance coverage of lead screening for children between the ages of one to two years to promote early detection through screening and to ensure that treatment starts before severe and irreversible harm is caused.

Excellus must fix its claims system and refund payments from 2005 through the present, plus 12 percent interest, to plan members and providers who paid for childhood lead screening claims when Excellus allegedly denied the claims in error.

Excellus will also create written training manuals and hold in-person training sessions about lead screening coverage for employees to analyze grievances and claim disputes, engage an independent entity to audit its compliance with the settlement and submit a report to Schneiderman documenting the providers and members to whom refunds were paid. In addition, Excellus must manually analyze all childhood lead screening denials over a six-month period to determine if any were erroneously denied and file a report of the findings with Schneiderman's office.

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