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NAIC: UnitedHealthcare meeting claim goals

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The health insurance arm of UnitedHealth Group Inc. (NYSE:UNH) has been doing a good job of meeting regulators’ claim and appeal goals, according to officials at the National Association of Insurance Commissioners (NAIC).

A 41-jurisdiction team led by regulators from Iowa, Arkansas, Connecticut, Florida and New York has decided to end a special monitoring effort, officials said.

The states began keeping close tabs on the UnitedHealth unit, UnitedHealthcare, in 2007, after insurance regulators who oversee 26 UnitedHealthcare-owned entities in 41 jurisdictions negotiated a regulatory settlement agreement with UnitedHealthcare.

The regulators began looking at UnitedHealthcare after doctors complained that UnitedHealthcare was taking too long to pay some claims and handle claim decision appeals.

UnitedHealthcare agreed to pay the states a $14 million assessment, officials said in a report on the monitoring project.

UnitedHealthcare also agreed to meet regulator-set benchmarks in 5 areas in 2008, 2009 and 2010. The company agreed, for example, that, by 2010, it would get its affiliates handle 97 percent claims accurately, handle 96 percent of claims in a timely fashion, handle 95 percent of non-clinical appeals and 97 percent of clinical appeals in a timely fashion, and reduce the percentage of insurance department complaints upheld to 35 percent.

About 100 regulators, independent examiner personnel and UnitedHealthcare personnel and representatives participated in the monitoring process, and the participants held about 500 meetings and conference calls, and the independent examiner devoted about 40,000 hours to assessment and review activities over a three-year period, officials said.

The team found that UnitedHealthcare met all benchmarks included by a wide margin in most years. In 2010, for example, insurance departments upheld only 23.1 of the complaints against UnitedHealthcare entities that they received, officials said.

The area in which UnitedHealthcare came closest to missing a performance goal was the 2007 clinical appeals benchmark. UnitedHealthcare entities were supposed to address 97 percent of clinical appeals within 30 business days of receiving the appeals and addressed 97.1 percent of the clinical appeals within that timeframe, officials said.

“The UnitedHealthcare Companies attained the benchmarks and achieved ‘compliance’ as contemplated by the terms of the agreement,” officials said. “As a result, no additional penalties were assessed.”

UnitedHealthcare told the state regulators that it will employ an independent consultant to help them continue to improve their claim payment process, officials said.

UnitedHealthcare put out a statement welcoming the multi-jurisdiction panel’s announcement.

“We are continuously enhancing our claim payment processes and customer service at UnitedHealthcare to meet the expectations of consumers, care providers, regulators and others we serve,” the company said. “The collaborative work we undertook with regulators in this innovative model helped create new best practices, as illustrated by our meeting the performance standards.

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