NYAG Enforces Health Insurance Coverage Issues with Two Enforcement Actions

"Plans and providers must take care to abide by the terms of their policies and contracts and not exacerbate the already significant financial burdens consumers face in getting the health care they need. At a time when legitimate medical bills are already an extraordinary burden on New Yorkers, improper billing and claims practices are even more deplorable."

GHI processed claims for certain key medical providers covered in its policy at its standard out-of-network rate which led to patients being billed for covered physician services — sometimes in amounts reaching thousands of dollars — when they should have been shielded from any expense, the NYAG's office stated.

Its parent company responded in a statement that, "more than a year ago, EmblemHealth recognized and addressed an error that affected a very small percentage of members in our PPO and EPO plans." 

"As a result, these members received less than full reimbursement for services provided by certain non-participating physicians. This has been corrected. The company has fully cooperated with the New York Attorney General's office to resolve this fairly and as promptly as possible for our members."

EmblemHealth also stated it has modified its policies and provided customer service staff with additional training. 

In the case of NYMDC, it was allegedly billing patients the difference between NYMDC's charge and the payment by the patient's health plan, despite the fact that NYMDC, as a participating provider with the health plan, was required to accept the plan's payment as payment in full, the AG's office charged.  

This practice, known as "balance billing," is prohibited by New York law and the provider's contractual obligations.

NYMDC, a small provider located in Kew Gardens, Queens, will now send refunds to affected patients who were improperly billed for services that were covered by their health insurance plans. An email to it was not returned by press-time.

NYMDC also agreed to retain an auditor to ensure all eligible consumers are given refunds and notices will be sent to patients. Further, NYMDC shall ensure that all collection activities cease and patients' credit standing is restored to good order. In addition to providing reimbursement, the agreement provides that NYMDC reforms its practices, train its employees, and pay a penalty of $7,500, the NYAG's office stated.