July 25, 2016

Missouri insurance regulators resolve United Healthcare dispute

Jefferson City, Mo - The Missouri Department of Insurance recently reached an agreement with United Healthcare Insurance Company, All Savers Insurance Company and United Healthcare Life Insurance Company to resolve allegations that the insurers "unlawfully restricted member's access" to members own medical providers by utilizing primary care physicians as "gatekeepers."  Gatekeepers are insurer physicians, who had to give permission or a referral before a member could see or be treated by another in-network provider.  

"Consumers should not have to incur the extra time, cost, delay and hassle of going through a 'gatekeeper' just to get access to the their very own doctor already in their very own network," said Department of Insurance Director John M. Huff. "I applaud our market conduct team for working to stop this unnecessary delay of health care access for Missouri consumers."

United Healthcare agreed to cease imposing referral requirements on claims from non-HMO group policies beginning in October 2016.  The company will also transition small and large group business to non-HMO products that do not have gatekeeper requirements.

The settlement agreement also provides that United Healthcare and its affiliated company All Savers Insurance Company will pay  "direct access," claims, that were improperly denied or reduced for lack of a referral.  Direct access claims are those claims for certain types of services or specialists, like gynecologists, where patients are not required to have referrals in order to access these services.

In the agreement, the department also alleges that United Healthcare made false entries in statements used in an investigation, by providing the department with transcripts of two call recordings relating to a member complaint that did not accurately reflect the content of the calls.

In the settlement, the companies agreed to develop written policies and procedures to ensure information provided to the department is complete and accurate. They also agreed to maintain all recordings made in connection with the handling of claims for three years and to provide those recordings to the department upon request.  

As part of the settlement United Healthcare paid a fine of $150,000.

About the Missouri Department of Insurance, Financial Institutions & Professional Registration

The Missouri Department of Insurance, Financial Institutions and Professional Registration (DIFP) is responsible for consumer protection through the regulation of financial industries and professionals. The department's seven divisions work to enforce state regulations both efficiently and effectively while encouraging a competitive environment for industries and professions to ensure consumers have access to quality products.

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