HARRISBURG, Pa. (WTAJ)– A hospital that has multiple health centers across Pennsylvania was violating medical claims that were being processed, the Pennsylvania Insurance Department (PID) announced.

In a news release issued Wednesday, Acting Insurance Commissioner Michael Humphreys said that Geisinger’s violations were found during a “comprehensive Affordable Care Act (ACA) market conduct examination.” The PID said that Geisinger was cooperative in the exams that were from Jan. 1, 2015, to March 31, 2016, and Jan. 1, 2017, to March 31, 2018.

Geisinger responded on Thursday to WTAJ and said in an emailed statement that the exam helped the hospital main’s focus which is to focus on improving easier access to health services for local communities.

We appreciate the opportunity to partner with the Insurance Department on opportunities to improve, which is very much aligned with Geisinger’s mission to make better health easier for the communities we serve. The review period for this most recent Market Conduct Exam dates back as far as January 2015, and we’re pleased to share that the violations cited in the report have either already been remediated or we are in the process of addressing them.

Geisinger

The state’s examinations discovered that when claims should have been paid, they were actually being denied by behavioral health service vendors, the release reads. Geisinger indicated that from 2016 to 2018 they made system changes that also included a whole new processing system for medical claims. In 2019, all all behavioral health operations were handled in house.

As punishment, Geisinger was ordered by the PID to reprocess incorrect claims and to make payment to those who filed them with applicable interest. The report also discovered Unfair Insurance Practices Act violations such as “unclear communications with members, maximum out-of-pocket miscalculations, and incomplete claim files,” the report states. Geisinger needs to show proof of restitution and, on top of that, pay a penalty of $125,000.

“The Insurance Department’s top priority is consumer protection within the marketplace, and these examinations are an opportunity for the department to ensure that companies are held to high standards and consumers are receiving the benefits to which they are entitled,” Humphreys said. “The results of the exam will see some consumers receiving restitution, as well as expected process improvements within the company.”

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More than $5.8 million has been paid in restitution to about 60,000 Pennsylvanians due to Affordable Care Act examinations, according to the PID. A full copy of the report can be read online at the PID’s website.