Improper Ambulance Service Payments Result in $363K Penalty Against Highmark

Navarro notes consumer reports spurred investigation

Following a nearly years-long Market Conduct investigation, Insurance Commissioner Trinidad Navarro announced today penalties against Highmark totaling $363,570 relating to improper volunteer ambulance company claims reimbursement. Investigations began after reports were received that payments were going to residents rather than directly to volunteer ambulance companies for payment of services.

“The cost of health care and complexity of insurance processes are already a burden on the minds of Delawareans. The last thing Delaware families need after a medical event requiring an ambulance is to receive mixed messages on the cost,” shared Commissioner Navarro. “The practice of sending mysterious checks to residents and waiting for them to be separately billed by the volunteer ambulance company rather than following the law and paying the provider directly causes confusion and delays for all involved. We’re grateful that consumers reported this issue so we could act.”

Through the 33-month period investigated, nearly 400 claims were found to be paid by Highmark to the subscriber or a third party, rather than to the volunteer ambulance company as required by law. This delays, or wholly prevents, much-needed reimbursements from reaching the volunteer ambulance companies, while causing confusion for the consumer and in some cases prompting them to be billed directly by the ambulance company.

Also identified were 89 instances of refusing to pay claims without conducting a reasonable investigation based upon all available information. These improper claims rejections occurred in cases where patients presented symptoms at a physician’s office but required emergency care and were transported to a hospital/facility.