News Release, Attorney General for the State Of Maryland
Annual Report Reveals More Than 50% of Carrier Denials Are Overturned or Modified When Consumers Seek HEAU Assistance
BALTIMORE, MD (November 6, 2019) – Maryland Attorney General Brian E. Frosh announced today that the Health Education and Advocacy Unit (HEAU) within the Consumer Protection Division of the Office of the Attorney General closed 1,974 cases in the Fiscal Year 2019, assisting patients in saving or recovering nearly $2.5 million. The information was included as a 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.
The HEAU offers mediation services to consumers who have a 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.
“When consumers seek assistance from the Health Education and Advocacy Unit, carrier denials are overturned or modified more than 50% of the time,” said Attorney General Frosh. “The HEAU continues to obtain positive outcomes for consumers who file complaints with the office.”
In one case mediated by the HEAU, the mother of a minor contacted the HEAU after attempting to refill a medication needed by her daughter for a rare endocrine disorder. The copayment for the medication had increased from $150 to $764.50—an increase of over 400 percent—for a 90-day supply after her federal employee pharmacy benefit manager moved the drug to Tier 3, its non-preferred drug list. The HEAU assisted the consumer in obtaining a renewable formulary tier exception through the end of 2019.
In two separate cases mediated by the HEAU, newborn infants at hospitals that were in-network with the parents’ health plans were, unbeknownst to the parents, examined by the hospitals’ out-of-network pediatric medical group. The claims for these services were processed as out-of-network by the carriers, leaving each set of parents with balance bills of $1,175 and $1,456, respectively. In one of these cases, the birth mother had experienced this exact same scenario with her first child and specifically asked that no pediatric services be performed by out-of-network providers. HEAU assisted both sets of parents in appealing the denials and contesting the balance billing with the out-of-network pediatric medical group, resulting in a reversal of those denials.
Of the cases closed by the HEAU in FY 2019, 808 were appeals and grievances-related cases. The HEAU mediation process resulted in health plans overturning or modifying 53% of their denials and resulted in health plans changing their decisions 59% of the time in cases involving at least one Maryland Insurance Administration (MIA) regulated plan.
Copies of previous years’ reports can be foundhere.
Consumers seeking assistance from the Health Education and Advocacy Unit can call the Unit’s Hotline at 410-528-1840 (en Español: 410-230-1712) or file a complaint online at www.MarylandCares.org.