R.I. fines UnitedHealthcare $100,000 over rehab, detox coverage decisions – The Boston Globe

PROVIDENCE — Rhode Island’s health insurance regulator fined UnitedHealthcare $100,000 over allegations that it didn’t follow state law when it made coverage decisions for treatments like drug rehabilitation and detox.

United did not admit to wrongdoing in resolving the issue earlier this month, but it will have to submit a corrective action plan. The company also agreed to come up with a plan for the people who were denied coverage or reimbursement for substance use disorder treatment from mid-2015 to early 2019. That could involve restitution for those who may have been harmed.

United denied coverage in 67 cases while using guidelines that were inconsistent with state law, according to Rhode Island’s Office of the Health Insurance Commissioner. According to the consent agreement, United determined that the coverage in those cases — which included residential and outpatient treatment for substance use disorders — didn’t meet medical necessity criteria.

“I thank the Office of the Health Insurance Commissioner for their full review of this matter and for continuing to hold health insurance companies accountable when their practices are not consistent with Rhode Island law,” Governor Dan McKee said in a news release Wednesday.

According to the health insurance commissioner, state law requires health insurers to make coverage decisions based on guidelines set by the American Society of Addiction Medicine. But United’s coverage criteria from 2015 to 2018 was “materially inconsistent” with those standards, the commissioner’s office said. Those standards also went against the standards of care among substance use treatment providers.

That probably resulted in “clinically inappropriate coverage decisions,” the commissioner said.

The regulatory action has been going on since 2019.

Brian Amaral can be reached at brian.amaral@globe.com. Follow him on Twitter @bamaral44.