Excellus fined $1M for denying ER claims


Excellus Blue Cross Blue Shield was fined almost $1 million for improperly denying emergency room claims and failing to explain benefits to its members.

The New York Department of Financial Services announced Thursday that the Rochester-based insurer improperly denied 166 emergency room claims between 2003 and 2007, reported the Democrat and Chronicle.

Excellus said the improper denials were caused by a claims processing systems failure that occurred when members already had paid the providers by the time Excellus processed the claims, according to the Rochester Business Journal.

The state department also determined that Excellus failed to provide members with explanation-of-benefits statements for the more than 337,000 pharmaceutical drug coverage claims it processed during the same four years, the Greater Binghamton Business Journal reported. Insurers are required under New York law to mail explanation-of-benefit notices for each processed claim.

Excellus already reimbursed consumers for the claims errors and said it would resolve the systems error issue and improve future practices.

"As the superintendent noted, we've been working with the department to address any outstanding issues," said Excellus Vice President of Communications Elizabeth Martin. "The health plan, meanwhile, is committed to retaining national recognition for providing high-quality services at lower-than-average costs."

To learn more:
- read the Greater Binghamton Business Journal article
- see the Democrat and Chronicle article
- check out the Rochester Business Journal article

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