Brown Subpoenas Health Plans over Claims Denials and Rate Hikes

Feb. 25, 2010, Los Angeles-Attorney General Edmund G. Brown Jr., who has an ongoing investigation into possibly illegal practices by some California health insurers, today subpoenaed financial records and other documents from California's seven largest health insurance companies.

"We have been looking at these companies for a number of months and are very concerned that some of them are unjustly raising premiums and denying payment of legitimate claims," Brown said. "Not only are the rate increases devastating to Californians strapped by the economy, but in some cases, they are possibly illegal."

"Our best attorneys are going to get to the bottom of this, and where we find violations of California's unfair business laws, we intend to stop them," Brown added.

Brown subpoenaed records from Aetna Health, Anthem Blue Cross, CIGNA, Health Net, Blue Shield of California, Kaiser Permanente and PacifiCare. Today's subpoenas cover pay-for-service health plans, which are health plans that reimburse doctors and hospitals for services performed instead of a health maintenance organization (HMO) approach. Brown revealed that his office served subpoenas to those same companies last month regarding their managed care plans, known as HMOs.

Brown said the insurance companies have 30 days to hand over their financial and other records.

Brown began an official inquiry last September into HMO practices of reviewing and paying insurance claims submitted by doctors, hospitals and other medical providers. The investigation was prompted by reports that California's five largest health insurance providers were denying insurance claims at rates of up to 39.6 percent.

Recently, Anthem Blue Cross announced to its members that it planned to hike premium rates by as much as 39 percent. Brown's investigation will probe whether the other health plans are planning similar rate hikes and will consider whether Anthem's steep rate increases for individual California consumers are fair under California law.

The investigation will include an examination of how much the plans are spending on health care versus non-healthcare costs such as marketing, administration and profits. The plans have been asked to provide detailed information on how they spend policy-holders' premiums and how they review claims and decide whether and how much to pay the doctor or hospital for the service.

The investigation also will examine:
- Member and medical provider complaints against the health plans describing payment delays, reduced payments and denials of payment claims, and the health plans responses to those complaints;
- How health plans determine doctor and hospital rankings and whether those rankings mislead customers on quality;
- Whether the health plans intend to raise premiums, and, if so, whether the plans disclosed the amount and frequency of the premium increases at the time of enrollment;
- Whether the health plans offer alternative policies to members when they increase premiums and whether the plans may deny enrollment in the alternative policies based on preexisting conditions.

Brown's investigation will look for violations of law, including California's Unfair Competition Law (Business & Professions Code section 17200) and False Advertising Law (Business & Professions Code section 17500.) These laws prohibit "any unlawful, unfair or fraudulent business act or practice" and the use of "false or misleading statements" to the public.

The attorney general is authorized to prosecute violations of the Unfair Competition Law criminally or file a civil law enforcement action to obtain an injunction forcing the company to stop the business practices, restitution of money to affected consumers and civil penalties beyond those available to private parties.

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