UnitedHealthcare agreed to reimburse nearly $930,000 to hospitals and radiology providers in more than 300 cases and to pay $613,000 in penalties after an internal audit of its own utilization review process found some claims were inappropriately denied.
The self-review was prompted by the Maryland Insurance Administration's (MIA) investigation of utilization review procedures used by United and its subsidiaries, which uncovered the use of noncompliant procedures.
Maryland Insurance Commissioner Ralph Tyler said United's cooperation with the probe and its internal audit made it easier to identify erroneously denied claims submitted by hospitals and radiology providers.
Routine required filings by United revealed issues with two programs designed to alert the company when physicians recommended that United's members receive elective hospital care or radiology services.
These programs did not meet all the requirements of the Maryland law for utilization review programs and placed inappropriate demands on hospitals and physicians referring patients for radiology services.
United's audit of the hospital program identified 85 cases of inappropriate payment denials of $756,130 in charges.
Similarly, United's audit of the radiology program identified 227 cases of inappropriate payment denials of $172,599 in charges. United agreed to pay the hospital and radiology claims associated with these cases. For these two programs, United also agreed to pay a penalty of $613,000.
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