Georgia fines Blue Cross Blue Shield $5M over 'serious' claims issues

ATLANTA - Georgia officials have fined insurance carrier Blue Cross Blue Shield $5 million after an investigation into regulator violations.

Tuesday, Insurance and Safety Fire Commissioner John F. King said the fine came after a months-long looking into the violation of state laws and agency rules and regulations by Blue Cross Blue Shield Healthcare Plan of Georgia Inc. 

King said he began the investigation after receiving numerous complaints from individuals, doctors, hospitals, and more across Georgia about the insurance carrier's operations.

"This examination uncovered a number of serious issues, including improper claims settlement practices, violations of the Prompt Pay Act, failure to reply to consumer complaints in a timely manner, inaccurate provider directories, and significant delays in loading provider contracts," King said. "As a result, our office has issued the largest fine in Agency history, with potential additional penalties if certain benchmarks are not reached."

In the order released with the announcement, officials note the most complained about errors with the carrier were connected to in-network claims processed as out-of-networks and claims that were rejected for unknown reasons. While Blue Cross Blue Shield tried to replace its provider database system, authorities say it failed to promptly investigate or settle claims.

The order rules that Blue Cross Blue Shield must follow a "Corrective Action Plan" and submit a monthly report to officials. The company may be fined more if it fails to meet certain benchmarks.

"To avoid additional penalties, Blue Cross Blue Shield must develop a new process for handling regulatory provider complaints, pay claims within the timeframes established under state law, and load provider contracts in a timely manner," officials said.

This is the largest fine in the Insurance and Safety Fire Commissioner history.

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