New York-based Group Health Incorporated, a subsidiary of EmblemHealth, has agreed to establish a $3.5 million consumer assistance fund to provide financial relief to members for its violations of out of network disclosure requirements.
As part of the settlement, GHI also agreed to provide improved plan disclosures for out of network provider benefits and pay $300,000 in penalties to the government.
The investigation into GHI began in 2013 after several complaints were made to the Health Care Bureau in New York concerning GHI's Comprehensive Benefits Plan, which is a health plan offered to New York employees and retirees.
The CBP allows plan members to receive care from physicians who are not in their plan's provider network. However, the CBP reimbursement rate is outdated, and rarely comes close to covering the amount billed.
The investigation found GHI's disclosures regarding the CBP's out of network coverage were inadequate and did not inform members about the low reimbursement rates. The investigation also revealed GHI failed to inform members of the potential medical bills they could incur from seeking care from providers outside of their network.
The agreement between GHI and the government requires the company to make the fee reimbursement schedule accessible and transparent to members and prospective members and to provide members with clear information regarding how they would incur out network charges. In addition, GHI has agreed to create a web portal that provides information on how much GHI will reimburse members for services provided by out of network providers.
More articles on healthcare industry settlements:
10 recent healthcare industry lawsuits, settlements
10 largest False Claims, Stark Law and Anti-Kickback settlements of 2014
New York Heart Center to pay $1.34 million to settle FCA, Stark Law allegations