Many insurers in the commercial space have not yet undergone a market conduct exam, while others have not been tested on elements such as mental health parity
Most plans have a well-defined process for responding to common state and federal audits. However, many plans are not as familiar with or prepared for the less frequent and less predictable market conduct examination.
State insurance departments use market conduct exams to assess a health insurance company’s performance and ensure that consumers receive promised services. The exam also determines if an organizations complies with federal and state regulations, and that it’s operating in an ethical and fiscally sound manner.
Poor market conduct exam performance may result in monetary penalties, further investigation by state departments, corrective action plans, legal action, or other measures that remediate any impacts to consumers — all of which can cause reputational harm. In 2020, exams in Illinois led to more than $2 million in fines, and exams in Pennsylvania resulted in approximately $1 million in fines. In 2022, an Illinois plan paid $1.25 million in fines.
To ensure your plan’s market conduct exam readiness, we recommend routinely assessing exam focus areas. ATTAC Consulting Group can help your organization:
- Understand The National Association of Insurance Commissioners (NAIC) market conduct examination requirements and process
- Assess your organization’s readiness for an exam, with particular focus on high-risk areas:
- Mental health parity
- Enrollment and disenrollment
- Premium billing
- Claims processing accuracy
- Grievance management
- Network adequacy
- Implement tools and processes for successfully navigating a market conduct exam
- Monitor and assess state and federal regulatory requirements for changes impacting health plans
- Develop and execute risk remediation plans
Contact ATTAC Consulting Group to learn more about how our expert audit team can help you prepare for a market conduct exam.
