Annual Report Reveals a 76% Increase Over the Last Three Fiscal Years inAdverse Decisions by Insurance Carriers

BALTIMORE, MD (November 9, 2018) – Maryland Attorney General Brian E. Frosh announced today that the Health Education Advocacy Unit (HEAU) within the Consumer Protection Division of the Office of the Attorney General closed 2,290 cases in Fiscal Year 2018,assisting patients in saving or recovering over $2.8 million.

The information was included as apart of the comprehensive Annual Report on the Health Insurance Carrier Appeals and Grievances Process that must be submitted to the Governor and General Assembly each year.The HEAU offers mediation services to consumers who have billing or other business-related disputes with their healthcare providers or coverage disputes with their health benefit plans. 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.

“Health carriers that inappropriately deny claims cause emotional and financial burdens for Marylander consumers,” said Attorney General Frosh. “We continue to see large numbers of adverse decisions that can sometimes deny a patient necessary, lifesaving treatment. As a result of the work of the HEAU, our office continues to see disputed cases achieve positive outcomes.”In one case mediated by the HEAU, a newborn—who was born seven weeks premature in a Maryland hospital—required a 16-day stay in the neonatal intensive care unit. The neonatologists who treated the premature infant submitted claims for payment to the HMO.

These claims were denied because, according to the HMO, the medical codes entered by the neonatology group were not consistent with neonatal care. The HEAU intervened, resolved the medical coding issue, saving the new parents approximately $4,300.In another case, a patient diagnosed with high-risk prostate cancer, with only a 30 percent survival rate when treated by surgery alone, petitioned his insurance to cover his participation in a clinical trial for new treatment.

After the insurance company denied coverage for the trial, the HEAU intervened, provided the necessary evidence to favorably resolve the dispute, and coverage was approved the next day. The patient recently contacted the HEAU to announce that he is cancer-free, and his quality of life has been restored. In FY 2018, Maryland-regulated carriers—health insurance issuers, nonprofit health service plans, HMOs, dental plans, and other entities that offer health benefit plans subject to regulation by the State—reported denying all or part of 76,115 claims for coverage because the carrier deemed the service not medically necessary, appropriate, or efficient.

These types of denials are known as “adverse decisions.” In FY 2018 there were 9,015 more adverse decisions than in FY2017, 21,393 more adverse decisions than in FY 2016, and 32,839 more adverse decisions than in FY 2015.Of the 2,290 cases closed by the HEAU in FY 2018, 1,000 were appeals and grievances-related cases. Of those cases, 71% involved assisting consumers with mediating or filing grievances regarding claim denials by their health plans.

The HEAU mediation process resulted in health plans overturning or modifying 49% of their denials, and resulted in health plans changing their decisions 58% of the time in cases involving at least one Maryland Insurance Administration(MIA) regulated plan.

Copies of previous year’s reports can be found here