Maryland Attorney General Brian E. Frosh announced on Thursday that the Health Education and Advocacy Unit (HEAU) within the Consumer Protection Division of the Office of the Attorney General closed 1,695 cases in Fiscal Year 2022, assisting patients in saving or recovering over $2.4 million, including more than $1.7 million in appeals and grievances cases. The information was included as part of the comprehensive Annual Report on the Health Insurance Carrier Appeals and Grievances Process that must be submitted to the General Assembly each year.
Per the press release: The HEAU offers mediation services to consumers with health insurance and medical billing issues, hospital financial assistance applications, medical debt collection, and access to medical records. The Unit also helps consumers who have been denied enrollment in a Qualified Health Plan or denied Advanced Premium Tax Credits or Cost-Sharing Reductions by Maryland Health Connection, Maryland’s health insurance marketplace. “Our HEAU can provide help to Marylanders when they are denied healthcare services or coverage,” said Attorney General Frosh. “These denials are incredibly hard on patients and their families and can even, at times, deprive patients of lifesaving treatment.”
The HEAU Annual Report reflects that denials of coverage happen routinely without challenge. In fact, consumers challenged less than 11 percent of adverse decisions in FY 2022, although many carriers issued more adverse decisions in FY 2022 than in FY 2021.In one case mediated by the HEAU, a 42-year-old woman diagnosed with psoriatic arthritis had been stable on Remicade infusions every six weeks when the carrier abruptly denied her Remicade claim, indicating it would not authorize a higher dose or frequency than stated in the FDA guidelines. She appealed the denial, including a statement from her rheumatologist indicating the denial would cause pain and irreversible damage to the patient’s joints. With the HEAU’s intervention, the denial was overturned, and the prior dosage and frequency resumed. Other complaints about the same carrier for denied medication claims not withstanding each patient’s established need for tailored, medically necessary treatments – were received by the HEAU, and those denials were also overturned.
In another case mediated by the HEAU, a 31-year-old woman was referred to an oral surgeon for diagnostic evaluation of a cyst in her jaw. The oral surgeon referred the patient for a CT scan. Upon receipt of the scan, the oral surgeon performed a biopsy, and the tissue was sent to pathology. The provider submitted the claim to the patient’s medical insurance carrier, but the carrier denied the claim ($5,000) for myriad reasons including contending dental codes were used rather than medical codes. The patient was stuck in the middle of conflicting contentions by the provider’s billing staff and the carrier until she filed a complaint with the HEAU. The HEAU mediated the coding/coverage conflicts resulting in full payment of the claims.
The HEAU also assists consumers faced with surprise medical bills, which has been a persistent problem for consumers both in Maryland and nationally. The No Surprises Act, which became effective January 1, 2022, established new protections from surprise billing and excessive cost sharing for consumers receiving healthcare items and services in emergency situations and at in- network facilities. The HEAU anticipates more consumers will be seeking assistance with expanded access rights to out-of-network mental health/substance use disorder providers at in- network cost.
Of the cases closed by the HEAU in FY 2022, 592 were appeals and grievances-related cases. The HEAU mediation process resulted in health plans’ original denials being overturned or modified 62 percent of the time. When the original denial is not overturned or modified, the HEAU is often able to negotiate a reduction in the billed fee from the provider, and set up reasonable payment plans for consumers. Individuals who experience wrongful denials of care or insurance coverage can contact the HEAU by filing a complaint on the Attorney General’s website or calling 410-528-1840.