BALTIMORE, MD—Maryland Attorney General Anthony G. Brown recently announced that the Health Education and Advocacy Unit (HEAU) within his Consumer Protection Division closed 2,037 cases in Fiscal Year 2023, helping patients save or recover over $3.3 million dollars, including more than $2.6 million in appeals and grievances cases. The information was included as a part of the comprehensive Annual Report on the Health Insurance Carrier Appeals and Grievances Process (PDF) that was submitted to the General Assembly.
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 problems enrolling in a private health plan on Maryland Health Connection, the state’s health insurance marketplace, or obtaining financial assistance to lower the cost of coverage.
“Navigating the health care system in this country can be complicated and receiving quality care can be expensive. Consumers are often squeezed between what their plan covers and what health care providers bill, which puts a financial and emotional strain on Marylanders seeking care,” said Attorney General Brown. “We encourage residents to contact the HEAU when they are denied coverage or need help understanding and mediating complex medical bills.”
The HEAU Annual Report reveals that denials of insurance coverage occur routinely without challenge. In fact, according to data reported by the carriers, consumers challenged only 8% of adverse decisions in FY 2023, although collectively, reporting carriers issued far more adverse decisions in FY 2023 than in FY 2022. Notably, in FY 2023, the eight carriers that reported more than 1,000 adverse decisions reported increases in denial decisions between 20 and 495%.
In one case mediated by the HEAU, a 53-year-old woman was referred to a neurologist after experiencing a transient ischemic attack (TIA or “mini-stroke”). She also had a history of complex migraines. She had tried various medications for treatment of her migraines with no improvement, and in one instance she suffered a severe reaction. Her doctor tried her on a particular migraine medicine and the patient experienced significant improvement. However, when he tried to get the medication pre-authorized for regular, ongoing use, the insurance company denied it, despite the fact that the other medicine had already been tried and failed to improve the patient’s symptoms. The HEAU successfully appealed the denial on the patient’s behalf, and it was reversed, saving the patient $980/per month in out-of-pocket costs.
In another case mediated by the HEAU, a claim for a diagnostic scan for a 16-year-old girl with a rare type of cancer was denied by the insurance carrier as not “medically necessary.” She was also experiencing symptoms of another rare condition, and her medical team was unsure whether it was related to the cancer, so they sought the scan to determine the best treatment plan for her. The carrier denied the first appeal, but after the HEAU filed a second appeal, the denial was overturned.
The HEAU also assists consumers faced with surprise medical bills, which has been an ongoing 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 high out-of-pocket costs for consumers in emergency situations or in other cases when consumers have no control over who provides them services. In one recent No Surprises Act case, a patient went to the emergency room of her local hospital but was then transferred to another facility that was out-of-network. Her carrier initially determined she would be responsible for 35% of the bill (her out-of-network cost). The HEAU appealed, and the carrier agreed to reduce the patient’s cost to 15% of the bill (her in-network cost) as required by the No Surprises Act for emergency services.
Of the cases closed by the HEAU in FY 2023, the Unit mediated 504 appeals and grievances-related cases. The HEAU mediation process resulted in health plans’ original denials being overturned or modified 57% of the time. Even when the original denial is not overturned or modified, the HEAU is often able to negotiate a reduced fee and assist with setting up reasonable payment plans.
Copies of previous years’ reports can be found online here.
Consumers seeking assistance from the Health Education and Advocacy Unit can call the Unit’s Hotline Monday to Friday, 10 a.m. to 2 p.m., at 410-528-1840 or file a complaint online at https://www.MarylandCares.org.