In FY 2015, more than 9,000 consumers contacted the Health Education and Advocacy Unit (HEAU) hotline in the Consumer Protection Division of the Office of the Attorney General of Maryland for assistance. The HEAU recovered or saved consumers more than $3.2 million dollars in FY 2015. Below are some examples of what HEAU has accomplished on behalf of some consumers. Names of consumes have been changed to protect identity.
A 62-year-old female, Ann, began suffering from severe stomach pains that sent her to the emergency room twice and led to a series of tests to uncover the cause. She had health insurance, understood her policy, and had already met her $3,000 deductible. Ann assumed her insurance would cover her bills. She was wrong. The insurance company contended that the deductible had not been reached, and it wouldn't pay the hospital bills or the bill of the doctor who treated her in the hospital. Ann spent months trying to prove that her deductible had been met. She was not successful. She contacted the HEAU and within several weeks, after our Ombudsman, who has been helping consumers like Ann for over 16 years, contacted the carrier. The carrier paid the bills. This saved Ann from collections actions for over $1,200 in outstanding bills.
Frank suffers with a severe case of plaque psoriasis. Over the years, Frank has tried numerous medications to deal with his psoriasis; he has tried topical ointments, topical steroids, phototherapy, Cyclosporine, Methotrexate, Raptive, Humira, and Embrel. Eventually Frank was prescribed Stelara, the only drug that has given him any noticeable relief. When Frank's doctor submitted a letter to the carrier for preapproval of the medication, the doctor stated that all other previous treatments had failed. His carrier denied the treatment saying the physician's letter did not adequately prove medical necessity and that the doctor needed to start prescribing according to the carrier's steps. Frank called the HEAU and told the story of his denial to one of our Ombudsman. Our Ombudsman, a nurse with over 40 years of healthcare experience, contacted Frank's provider, reviewed all of Frank's records and provided a comprehensive outline with documentation of all of Frank's prior therapeutic steps. Frank's health insurance company eventually approved the prescription, providing Frank the relief he needed.
Mary, a college student in Maryland attending a Maryland college on a student visa, has a history of seizures. Mary enrolled in a student health insurance plan. During a routine visit with her neurologist, a frontal lobe tumor was found, necessitating surgery to remove it. According to all of her health care providers, the seizures were completely unrelated to the tumor. Mary's health insurance carrier refused to cover the tumor-related treatment based on a pre-existing condition exclusion for the seizures. Despite the efforts of her health care team, the carrier continued its refusal. Mary contacted the HEAU for help. An HEAU Ombudsman contacted all the medical providers involved (over a dozen) who had sent her a bill. The Ombudsman explained to Mary's providers that Mary was working with the HEAU to get the insurance company to pay their bills, the Ombudsman requested the providers delay any action to send Mary's account to collections until the HEAU had a definitive determination of whether the insurance company was going to reimburse for the medical bills involved. After little success with the insurance company's front office, our Ombudsman contacted the regulatory analyst in the legal department, who after reviewing the entire file and the HEAU's correspondence and advocacy package, determined that the claims should be paid.
Health Education and Advocacy Unit
Consumer Protection Division Maryland Attorney General's Office
410-528-1840 or 877-261-8807 (toll free)www.oag.state.md.us/consumer/heau
200 St. Paul Place, Baltimore, MD 21202
410-576-6300 / 1-888-743-0023 toll-free / TDD: 410-576-6372