A 4-year investigation by the North Carolina Department of Insurance resulted in a very large fine against United Health Care related to its balance billing practices. The department found that UHC was not doing enough to protect members, who had Emergency Room care or Anesthesia, from balance billing by out of network providers.

A review of the complaints showed that members were being subjected to cost-sharing more than the applicable deductible, copayment, and coinsurance liabilities. State law also prohibits insurers from imposing cost-sharing for emergency services that differ from the cost-sharing that would have been imposed if the provider had been in-network, if a prudent layperson acting reasonably would have believed that a delay would have worsened the emergency or the choice of a provider was beyond the covered person’s control. The report also found that in several cases, when members filed grievances, UnitedHealthcare upheld its decision without any indication that efforts were made to intervene on behalf of the member to prevent them from being subjected to the difference between the amount billed and the companies’ allowed amount.

This action by the NC Insurance Department could lead UHC and other insurers to step up their Special Investigations Units to audit out of network providers, who routinely waive balance bills owed by patients, where the No Surprises Act or analogous state law no surprise statues are inapplicable.