North Dakota’s Insurance Department has fined Blue Cross Blue Shield of North Dakota $125,000 after a 16-month “market conduct exam” found it had improperly denied certain claims and failed to report some insurance fraud.
Insurance Commissioner Jon Godfread said the focus was on mental health and substance abuse claims. He said a lot of the problems came in disagreements over the level of treatment.
"Your doctor says, 'You need 10 days of in-patient treatment,' and Blue Cross may come back and say, 'No, you need three," Godfread said.
Godfread said he has asked the Blues to take another look at those claims.
"We want the Blues to try and tip the needle in favor of the member," Godfread said.
Godfread said Blue Cross was very amenable to make changes – and already he’s seeing some progress. He said the Blues have agreed to invest another $300,000 to address those issues.
"I'm optimistic that we will see a new and improved Blue Cross, that's going to err on the side of the member, for the time being," Godfread said. "I think it's long overdue."
Godfread said while the exam has been wrapped up, the Blues have hired an outside audit firm, to make sure to follow up the issues identified in the exam.