Claims Investigations

Managed Healthcare Unlimited (MHU) conducts focused investigations of health insurance companies’ claims payment procedures and operations. A “360 degree” approach by MHU subject matter experts in claims management and medical practice provides the broadest possible examination of an organization’s interrelated departments, thereby identifying deficiencies throughout the claims processing chain. As part of this examination, MHU staff assist regulators and health plans in understanding the complexities and root causes of claims-related grievances and provider disputes. Problems uncovered as part of this process are often the result of contractual arrangements among networks and providers that create confusion and unintended consequences for physicians and consumers, e.g., claim denials and unexpected bills.

The following cases exemplify MHU’s work in this area:

  • MHU reviewed pre-enrollment underwriting and post-enrollment rescission practices of five of the largest California health plans in collaboration with a state legal team. MHU staff developed research questions and review tools and conducted onsite visits. As a result of this audit, the plans modified their internal policies and review processes, the California legislature drafted proposed regulatory changes, and the state levied million-dollar penalties.
  • MHU investigated rescission and underwriting practices across seven health plans, resulting in the development of new legislative protections for consumers, including the abolition of the preexisting condition requirement.



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