Please ensure Javascript is enabled for purposes of website accessibility

AG reports $2.5M saved in FY19 health care disputes

The Maryland Office of the Attorney General reported Wednesday that more than 1,900 health care cost dispute cases were closed in fiscal year 2019, saving or recovering nearly $2.5 million for patients.

The Health Education and Advocacy Unit (HEAU) within the Consumer Protection Division offers mediation to consumers with billing or other business disputes with their health care providers or coverage disputes with their benefits plan, according to a news release from the office.

“When consumers seek assistance from the Health Education and Advocacy Unit, carrier denials are overturned or modified more than 50% of the time,” Attorney General Brian E. Frosh said in a statement. “The HEAU continues to obtain positive outcomes for consumers who file complaints with the office.”

Of the 1,974 cases closed in the last fiscal year, 808 were appeals and grievances-related cases. Mediation resulted in health plans overturning or modifying 53% of their denials and changing their decisions 59% of the time in cases involving at least one state-regulated plan, according to the release.

In one case, the mother of a minor contacted the unit because the copay on the refill of her daughter’s prescription medication for a rare endocrine disorder had increased from $150 to $764. The drug had been moved to a different tier by the employee pharmacy benefit manager and the HEAU assisted the woman in obtaining a tier exception.

In two cases mediated by the unit, newborn infants born at in-network hospitals were examined by out-of-network doctors, who billed the parents more than $1,000 in each case. One of the mothers had had the same experience when she gave birth to her first child and specifically requested that no out-of-network provider conduct examinations. Both sets of parents appealed the out-of-network medical group’s denials, which were reversed.

The HEAU report was prepared as part of the comprehensive Annual Report on the Health Insurance Carrier Appeals and Grievances Process, which is submitted each year to the General Assembly.

To purchase a reprint of this article, contact [email protected].