Maryland Attorney General Frosh announced that the Health Education Advocacy Unit, within the Consumer Protection Division, closed 2,487 cases in Fiscal Year 2017, assisting patients in saving or recovering nearly $3.7 million. This news comes from one of three sets of data included in the comprehensive Annual Report on the Health Insurance Carrier Appeals and Grievances Process that was submitted to the Governor and General Assembly.
The Health Education Advocacy Unit (HEAU) closed 1,145 appeals and grievances cases from July 1, 2016 to June 30, 2017, and mediated 867 of those cases. The mediation efforts resulted in the carrier’s overturning or modifying 51% of their denials. “While this number reflects positive results for consumers who reach out to the HEAU, it suggests that carriers are inappropriately denying claims, causing significant financial and emotional burden for consumers.” 4% of those cases were identified as mental health related cases and the success rate in mental health cases was 59%. The appendices include HEAU appeals and grievances data by carrier (including state-regulated vs. non-regulated coverage) and the outcome, as well as global data and data by denial type and by service type. HEAU does not assist with Medicare or Medicaid complaints, but can help with nearly all commercially insured plans.
Carrier-reported data indicate there were 67,100 adverse decisions in FY 2017, an increase of 12,378 over the previous year. 6,012 grievances were filed, of which 54% were overturned or modified by the carrier after the consumer filed the grievance. Only about 2% of grievances involved mental health or substance abuse, and of those only 25% were overturned or modified. The appendices include data by carrier on adverse decisions, grievances filed and the outcome, as well as global data, data by service type and some historical comparisons.
The report states that the Maryland Insurance Administration (MIA) investigated 365 grievances filed from July 1, 2016 to June 30, 2017, resulting in 68% of the denials being overturned or modified. During the course of the investigation, the carriers reversed themselves 53% of the time and the MIA overturned or modified 15% of them. Of those cases, 21 involved mental health or substance abuse, which were modified by the MIA 3 times and reversed by the carrier 10 times. [MIA’s jurisdiction is limited to state-regulated plans – see next column for more info.] The appendices include MIA data by carrier on grievances filed and the outcome, as well as global data and data by service type.