Texas Attorney General Ken Paxton opened an investigation into TriWest Healthcare Alliance Corp., the U.S. government contractor that administers the VA Community Care Network and the Defense Health Agency's TRICARE West Region, over reports that it wrongfully denied health care claims by falsely treating insureds as having other health insurance (OHI). The OAG has issued Civil Investigative Demands (CIDs) and plans to interview consumers and employees to determine whether TriWest violated the Texas Deceptive Trade Practices Act. No findings or penalties have been imposed yet.
No penalties or remedies have been imposed yet. As part of the ongoing investigation, the OAG has issued Civil Investigative Demands (CIDs) to TriWest and plans to conduct interviews with consumers and employees.
Organizations that use third-party administrators (TPAs) or health benefit contractors should review their administrator and vendor agreements for claims-processing accuracy standards, coordination-of-benefits (COB) and 'other health insurance' (OHI) data-matching provisions, and data-quality warranties covering eligibility and enrollment data feeds (the alleged violation arose from a vision plan being misread as OHI). Key clauses to scrutinize include: representations that the vendor will accurately classify coverage and promptly correct misclassifications; member appeal, grievance, and complaint-escalation requirements with defined response times; audit and reporting rights over claim denial rates and denial reasons; cooperation obligations for regulatory investigations and Civil Investigative Demands; and indemnification/hold-harmless provisions for deceptive trade practices or wrongful-claim-denial liability. Customer-facing health plan agreements should also be checked to ensure denial notices and coverage representations align with what is contractually promised to avoid DTPA exposure.
Entity
TriWest Healthcare Alliance Corp.
Industry
Insurance"TriWest Healthcare Alliance Corp."
"Attorney General Ken Paxton launched an investigation into TRICARE Insurance’s TriWest Healthcare Alliance Corp."
"This investigation stems from reports and admission that the company wrongfully denied health care claims."
"falsely claiming that the insured has other health insurance (“OHI”)"
"The investigation seeks to determine whether TriWest violated the Texas Deceptive Trade Practices Act (“DTPA”)."
"the Office of the Attorney General has issued Civil Investigative Demands (“CIDs”) to the company"
$3.0M
Texas Attorney General Ken Paxton announced a settlement requiring Temu to protect Texans’ sensitive personal data from exposure to the Chinese Communist Party and to strengthen product-safety practices. Temu must pay Texas $3 million, comply with data-security requirements backed by a potential $8 million annual penalty, conduct annual independent product testing, and take specified action on products found to contain harmful substances.
$773.0M
Texas Attorney General Ken Paxton announced that a multistate coalition had secured an opioid settlement with Albertsons, which would require the grocery chain to pay more than $773 million nationally once final. Texas and its political subdivisions may receive up to $57.8 million for opioid abatement; the release does not identify privacy violations.
Texas Attorney General Ken Paxton sued Gerber Products Company and Nestlé USA, Inc., alleging that Gerber made deceptive safety and testing claims while its baby food contained dangerous levels of toxic heavy metals. The lawsuit asserts claims under the Texas Deceptive Trade Practices Act; the release does not report a settlement, monetary penalty, or court order.
$1.5M
The Texas Attorney General obtained a judgment holding Rubinsky Roofing LLC liable for 27 violations of the Texas Deceptive Trade Practices Act, including deceptive practices involving older consumers and payment for unnecessary or unfinished repairs. The judgment requires more than $1.5 million in civil penalties, allocates at least $500,000 to consumer restitution, and permanently bars the company and its owner from the practices at issue.
The Texas Attorney General opened an investigation into UnitedHealth Group over allegations that its insurance-benefit administration and patient-care decisions denied Texans medically necessary healthcare. The AG issued Civil Investigative Demands to collect evidence; the release announces no penalty or remedy.
$7.5M
Texas Attorney General Ken Paxton announced a $7.5 million settlement with Tris Pharmaceuticals over alleged misrepresentations about the efficacy of Dyanavel XR, an ADHD drug marketed for children. The release says the company overstated the drug’s efficacy and directed sales representatives to make misleading claims to doctors, including Medicaid providers.