Benjamin M. Lawsky, Superintendent of Financial Services, today announced that Oxford Health has been fined $665,000 for failing to explain coverage to their health plan members. Oxford also failed to tell members how to challenge claims denials.

Oxford was cited for approximately 300,000 instances of failing to provide what are known as explanation of benefits statements. The statements, required under state law, are intended to describe what services the plans cover and how consumers can appeal when they believe claims are improperly denied.

The two Oxford companies fined are Oxford Health Plans NY Inc. and Oxford Health Insurance Inc. Oxford Health is owned by UnitedHealth Group.

In addition, the companies were cited for failing to facilitate a DFS examination of their conduct by not providing requested information in a timely or complete manner.

“Insurers must provide their members with clear descriptions of their benefits each and every time a claim is processed. Consumers have every right to know what their health plans cover, what the plans don’t cover, and what they can do when their claims have been denied improperly,” Superintendent Lawsky said. “This fine reflects the serious and systematic nature of the practices uncovered by the Department. At the same time, we are encouraged by Oxford’s commitment to addressing the Department’s findings and improving its performance going forward.”

The violations found in the DFS exam include:

• Failing to send explanation of benefits statements for certain claims which were denied in part or in full.
• Instances when the explanation of benefits statements that were sent failed to contain specific explanations of why claims were denied or not fully covered.
• Failing to make timely utilization reviews, the process used by insurers to make an initial determination about whether treatment being given to a plan member is medically necessary.
• Failing to give members required information about appeals processes that could be used when utilization reviews determined that coverage of medical treatment was being denied.

Oxford was also cited for failing to provide the Department with complete and accurate information in a timely manner on several occasions when examiners reviewed records and the insurers’ claims payments practices.

In a settlement with the Department, Oxford agreed to take steps necessary to prevent the violations from occurring again. The company agreed to revise procedures regarding issuing explanation of benefits statements and conducting utilization reviews.

The stipulations signed by Oxford can be found on the Department’s website, www.dfs.ny.gov.