(Los Angeles, CA – Insurance News 360) – A decade of legal battles over the implementation of the Unfair Insurance Practices Act (UIPA), the California Supreme Court denied review of the 4^th Appellate District’s decision that upheld Commissioner Dave Jones’ Fair Claims Settlement Practices Regulations. The regulations detail how insurance claims must be processed, and are the foundation of determining how many violations occur as part of the fine assessment process.

This allows the Department of Insurance to levy up to $91 million in fines against PacifiCare for numerous unfair claims practices, including wrongful denials for life-saving treatment for people battling serious illness and claim payment denials for providers and hospitals—all because the insurer was focused on maximizing profits through what it called “efficiencies” after the 2005 botched $9 billion acquisition of PacifiCare by UnitedHealthcare. Examinations revealed that the company knew about these issues.

Misrepresenting what medications or treatments an insurance policy covers, failing to promptly pay claims where liability is reasonably clear, and forcing claimants to file lawsuits to get full payment, and other acts are considered unfair practices. The Insurance Code allows the commissioner to impose fines of up to $5,000 each time an insurer commits an unfair act or practice on a consumer, or up to $10,000 each time if the insurer did so willfully.

“UnitedHealthcare purchased PacifiCare and imposed cost-cutting measures that destroyed PacifiCare’s claims-handling processes and its arguments in litigation that insurance companies should be allowed to willfully harm consumers as long as they don’t do it too often, reflect a gross disregard of the lives and well-being of the consumers who paid for the promise of coverage,” Commissioner Jones said. “Customers have no choice but to rely on the integrity of their health insurance companies. PacifiCare breached that trust. By any measure, 908,000 violations reflect a general business practice of violating consumer protection laws. I am delighted the Supreme Court has rejected further challenges to the insurance commissioner’s authority to punish insurance companies for knowingly harming even one consumer.”

Based on departmental examination results and following an administrative hearing that took three years, Insurance Commissioner Dave Jones found PacifiCare committed 908,547 separate violations of the UIPA, and he imposed fines aggregating $173,603,750 in penalties. On behalf of PacifiCare, UnitedHealthcare sued the commissioner, arguing that none of its harmful conduct violated the Insurance Code.

The Appeals Court rejected PacifiCare’s argument that insurers are immune from fines for unfair acts, stating “PacifiCare’s interpretation of section 790.03(h) is not only internally problematic, it stands in contrast to virtually every other statute the Legislature has enacted in connection with (1) enforcement of the Insurance Code against insurers generally; (2) enforcement of the UIPA in particular; and (3) the imposition of administrative penalties against insurers in other contexts.”

The court also rejected PacifiCare’s argument that the commissioner must prove an insurer had “actual knowledge” of its illegal conduct and held that it was within the commissioner’s authority to hold the insurer responsible if its agents or employees were aware of facts that would cause a reasonable person to know of the violations. The court also found the commissioner’s reasoning was sensible in that restricting the definition of “knowingly” to one particular individual’s actual knowledge would fail to take into account that many people handle a claim, and an unfair practice can be committed by cumulative acts, not simply the intentional act of one person.”

Source: California Insurance Department.

(Sacramento, CA – Insurance News 360) – On Jan. 2, the California Department of Insurance released the Prescription Drug Cost Transparency Report, which compiles information from nine health insurers about prescription drug coverage.

The report includes information on prescription drugs dispensed at a plan pharmacy, network pharmacy, or mail order pharmacy for outpatient use, and include the following drug categories: generic, brand name, and specialty. CDI-regulated insurers reported to the department the 25 most frequently prescribed drugs, the 25 most costly drugs by total annual plan spending, and the 25 drugs with the highest year-over-year increase in total annual plan spending for calendar year 2017 for individual and group coverage. This mandated reporting by insurers is meant to demonstrate the overall impact of drug costs on health insurance premiums in California.

“Our Prescription Drug Cost Transparency Report is an important first step toward providing more information for consumers and policymakers regarding the cost of drugs,” said Commissioner Jones. “More work needs to be done by policymakers to address the rising cost of drugs which significantly contribute to overall healthcare costs and health insurance premiums.”

Source: California Insurance Department.

(Washington, DC – Insurance News 360) – The U.S. Bureau of Labor Statistics’ Job Opening and Labor Turnover Survey for November revealed a drop to 6.9 million openings and a slight decrease in hires to 5.7 million, and a slight fall in quits to 3.4 million.

Job openings dropped 243,000 to 6.9 percent on the last day of November, and job openings in the private sector decreased by 237,000. There was little change in government.

Job openings in “other services” and construction both fell (66,000 and 45,000, respectively).

The number of new hires dropped by 218,000 to 5.7 million in November, and the rate of hires was 3.8 percent overall. The federal government increased hiring by 8,000 positions, but professional and business services fell by 167,000, and total private sector hires fell by 236,000.

Separations didn’t change much, with 5.5 million in November, and a rate of 3.7 percent. Total separations decreased in professional and business services (-122,000) and in accommodation and food services (-88,000). The number of total separations was little changed in all four regions. The number of quits fell by 112,000. In professional and business services, there was a drop of 84,000; accommodation and food services saw a decrease of 62,000.

Source: U. S. Bureau of Labor Statistics.

(Washington, D.C. – Insurance News 360) – The 14th annual survey of consumer engagement in health care shows that consumers are more cost-conscious and seek more information than in years past.

The Employee Benefit Research Institute and Greenwald & Associates conducted a consumer engagement survey that looked at value-based health insurance design, growth of high deductible plans and their impact on consumers’ behavior and attitudes.

The study revealed that nearly half of enrollees in a high deductible health plan were in a plan paired with a consumer-directed health plan (with a health savings account, or health reimbursement arrangement. Also, those who enrolled in high deductible plans are more engaged than traditional plan enrollees.

These are also more likely to look for information and exhibit cost-conscious behaviors. They are more likely to research doctors and hospitals, inquire about generic drug options, seek less costly treatment solutions, negotiate lower prices for services,and ask questions about coverage for specific medications. They are also more likely to create a budget for medical expenses, use online cost-tracking tools offered by healthcare providers, and take preventative measures to preserve health, including enrolling in wellness programs. But, those differences though, may be tied to outside factors.

“HDHP enrollees have a higher level of education than traditional plan enrollees, consider themselves to be in very good health, and receive a higher level of income,” said Paul Fronstin, Director of Health Education, Employee Benefits Research Institute. “It is important to remember that these advantages may drive people to select the HDHP option.”

Source: Employee Benefit Research Institute U.S.

(Little Rock, AR – Insurance News 360) – Arkansas Insurance Commissioner Allen Kerr made a statement on Jan. 7.

“Thanks to the hard work of Arkansas Insurance Department staff, we are able to issue these first licenses for pharmacy benefit managers following the passage of the new law in March.  This law protects Arkansas consumers and has sparked a nationwide conversation on how other states can help their citizens have continued access to needed prescriptions and information on cheaper pharmaceuticals.”

A Pharmacy Benefits Manager License for Aetna Health Management, LLC based in Hartford, Connecticut was one such approval. A second was granted to CaremarkPCS Health, L.L.C. of Scottsdale, Arizona.  Aetna Health Management does business in Arkansas as Aetna Pharmacy Management and is registered as a Foreign Limited Liability Company with the Secretary of State. CaremarkPCS Health does business in Arkansas as CVS Caremark and is registered as a Foreign Limited Liability Company.

Kerr also granted OmptumRX a 60-day conditional license, active Jan 1, upon the Department’s completion of the company’s application.

Source: Arkansas Insurance Department.