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BALTIMORE, MD (November 5, 2020) – Maryland Attorney General Brian E. Frosh announced today that the Health Education and Advocacy Unit (HEAU) of the Consumer Protection Division of the Office of the Attorney General closed 1,821 cases in the Fiscal Year 2020, assisting patients in saving or recovering over $4.3 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 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.
“Adverse decisions by health care carriers deprive, or threaten to deprive, patients of potentially lifesaving treatment, often causing enormous emotional and financial burdens for Marylanders,” said Attorney General Frosh. “We urge consumers to contact our HEAU for assistance when coverage for their care is denied. The HEAU provides a vital service to Marylanders who otherwise may have no recourse when denied health services or coverage.”
The HEAU Annual Report reflects that denials of coverage happen routinely without challenge. One major carrier reported issuing nearly 20,000 adverse decisions and consumers challenged the adverse decisions less than 10% of the time. Those that were challenged were overturned or modified by that carrier nearly 60% of the time.
In one case mediated by the HEAU, an infant who was diagnosed at 2 months with a rare disorder, Spinal Macular Atrophy, was prescribed a gene therapy medication that cures the disease with one injection if administered before 6 months of age. The medication is the only known treatment to cure the disease; life expectancy without timely administration is approximately 6-9 years. The infant’s health carrier refused to authorize coverage for the treatment, instead of authorizing a more conservative protocol to be administered over time. The family contacted the HEAU for assistance in appealing the denial. Upon filing the appeal, the family’s carrier overturned the denial and approved the medication.
In another case mediated by the HEAU, a Maryland resident who suffered a severe cardiac event was transported via air ambulance to a West Virginia cardiac care facility. The air ambulance, an out-of-network provider, filed a claim for $30,400 and was initially paid $8,220 by the patient’s governmental health plan. The air ambulance provider proceeded to persistently seek the $22,180 balance from the patient. The HEAU appealed and mediated the dispute between the air ambulance provider and the carrier. Ultimately, the health carrier paid an additional $5,911 and the air ambulance provider waived the remaining balance bill of $16,269.
The HEAU also assisted consumers faced with surprise medical bills, a persistent problem for consumers both in Maryland and nationally. In one case a mother was billed $9,254 by an out-of-network surgical group for a physician assistant who assisted with her obstetrical delivery at a hospital that was in-network with her health plan. She was not informed of the group’s out-of-network status or anticipated participation in her surgery before the delivery. The amount allowed by her health plan was $237. The surgical group sent her the balance bill of over $9,000 and persistently sought payment. The HEAU appealed and mediated the dispute, and the surgical group ultimately waived its balance bill. Another family faced a $29,335 bill from an out-of-network neonatologist who treated their newborn son during an 11-day ICU stay. With the HEAU’s help, their out-of-pocket costs were lowered to $461.
Of the cases closed by the HEAU in FY 2020, 741 were appeals and grievances-related cases. The HEAU mediation process resulted in health plans’ original denial being overturned or modified 50% 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.
Copies of previous years’ reports can be found here.
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 http://www.marylandcares.org.