FARGO - North Dakota insurance regulators will examine whether the state's largest private health insurer is properly handling behavioral health and substance abuse claims.
Insurance Commissioner Jon Godfread said the North Dakota Insurance Department will carry out a market conduct examination of Blue Cross Blue Shield of North Dakota's coverage practices involving mental health and substance abuse claims over a recent five-year period.
"In the face of the opioid and addiction crisis, it's extremely important to make sure North Dakotans with health insurance are receiving the benefits promised to them by their health insurance company," Godfread said.
The department conducts an examination of Blue Cross Blue Shield of North Dakota every three to five years as part of its routine oversight of the state's largest health insurer. The last examination was five years ago, Godfread said.
The focus of this year's examination stems from complaints insurance regulators have received from health insurance customers and behavioral health providers, Godfread said.
"We received some complaints and we want to make sure our consumers are receiving services they were promised," he said. "We believe it's a fair opportunity to go in and look."
To help with the examination, Godfread has hired a firm called Risk and Regulatory Consulting, which has previous experience involving examinations of the North Dakota Blues and is "familiar with their processes," he said.
"It's a difficult topic," evaluating behavioral health and substance abuse claims, requiring specialized expertise, Godfread said. "You've got to have qualified experts."
A spokeswoman for Blue Cross Blue Shield of North Dakota said market conduct examinations and audits are routine in the heavily regulated health insurance industry.
"In support of our members, we welcome the department's review and will cooperate fully," said Communications Director Andrea Dineen.
The examination also will review telehealth services coverage and claims, insurance fraud reporting and corporate governance, including subsidiary companies, among other areas.
Godfread noted that telehealth services are new, and insurers and providers are operating under recently adopted rules.
"It's a new area of service provision," he said. "We're really just ensuring that they're following the law."
Blue Cross Blue Shield of North Dakota will not have any other comments until the examination is completed, which Godfread said will take at least several months.