UHC Fined $536,000, Reopens 50,000 Claims

The Missouri Department of Insurance, Financial Institutions and Professional Registration has levied fines totaling $536,000 against UnitedHealthcare (UHC) of the Midwest, a subsidiary of UnitedHealth Group, and ordered them to re-examine 50,000-plus chiropractic claims dating back to November 2004. The department determined that UHC violated state insurance laws by limiting coverage to 26 annual visits and failed to evaluate the medical necessity of treatment before denying submitted claims. UHC must reimburse chiropractors for any claims it finds were improperly denied, including interest; and must do the same for patients when applicable. According to a 2004 Missouri law, health insurance companies must cover at least 26 chiropractic visits per year without prior authorization unless the treatment is determined to be medically unnecessary.

According to a settlement announced in late August, the Missouri Department of Insurance made the following determinations regarding UHC of the Midwest and its illegal reimbursement activity, noting that in some instances, the insurer:

• used a chiropractic rider that limited coverage in a calendar year;
• denied payment of benefits by limiting coverage to 26 visits per calendar year;
• failed to pay benefits for medically necessary care, in that it denied claims on the basis that the insured and the provider failed to submit or resubmit a Complete Clinical Notification (CCN) in order to obtain reimbursement, relying solely on administrative requirements rather than on any basis in medical necessity or lack thereof;
• denied payment of benefits for chiropractic care by failing to make any determination on the medical necessity of additional visits and by requiring notification within the first 26 periods in a policy period as a condition of coverage;
• failed to pay the appropriate amount on the claims it partially covered; and
• denied chiropractic claims by improperly coding the denials on the claims.

"When Missourians entrust their health coverage to an insurance company, they expect and deserve to be treated fairly and legally. We have taken this action to make sure that happens," said John M. Huff, director of the Missouri Department of Insurance. "We believe the review of these 50,000 files may determine money is due to other providers and possibly consumers."

UnitedHealthcare has been in the news several times in the past few years for its coverage and reimbursement tactics. For example, as reported in DC in 2007, UHC implemented a policy in several states that limited reimbursement for physical medicine and rehabilitation services to licensed providers only. That meant if non-licensed staff (chiropractic assistants, etc.) performed those services, they were considered non-reimbursable. And later that year, the insurer declared chiropractic manipulative treatments for pediatric and headache patients "unproven" and therefore not a covered service - a policy UHC ultimately rescinded following a collaborative response by major chiropractic organizations including the American Chiropractic Association, International Chiropractors Association, Council on Chiropractic Guidelines and Practice Parameters, and Congress of Chiropractic State Associations.

Chiropractors and chiropractic patients who do business with UnitedHealthcare of the Midwest can find out more about the settlement specifics and if they are eligible for reimbursement by calling the Missouri Department of Insurance consumer hotline (1-800-726-7390) or visiting www.insurance.mo.gov.