PacifiCare Responds to CDI Allegations

Cypress, Calif.-based PacifiCare is pushing back against allegations concerning its claims processing practices made by the California Department of Insurance (CDI). 

The Los Angeles Times reported that CDI is accusing PacifiCare of violating state law 992,936 times from 2006 to 2008. The allegations center upon the reimbursement rates for physicians and complaints from consumers that they were denied claims for covered procedures. With the state seeking fines as high as $10,000 for each of the alleged violations, the maximum penalty could be roughly $9.9 billion.

In a statement furnished to Insurance Networking News, the company, a subsidiary of Minneapolis-based UnitedHealth Group, denied wrongdoing.

“By all objective measures, PacifiCare pays its claims timely and accurately,” the statement reads. “Specifically, PacifiCare has met or exceeded all applicable claims processing standards, including standards expressly agreed upon by the CDI. We are committed to strong operational performance and maintaining a high level of service to physicians, hospitals and health plan members.” 

The company noted that PacifiCare of California was one of only three plans to receive the highest "four-star" rating by health plan members in the Statewide Office of the Patient Advocate's annual survey and that the National Committee for Quality Assurance, awarded the company its highest rating of "excellent" in 2010.