ANNAPOLIS – Maryland’s two-year-old health care appeals and grievance law is working well, according to a report released Thursday by the Maryland Insurance Administration.
The law, passed by the General Assembly in 1998, allows consumers to appeal a health insurer or HMO’s decision to deny coverage for procedures the carrier believes are not “medically necessary.”
Last year, the insurance commissioner issued 68 orders to insurers, including a tonsillectomy for an adult suffering from sleep apnea, two breast reduction operations and scar removal for a 19-year-old woman who had been in a car accident. An order can be a direction that the service be covered or a letter of reproof.
“I think it has been very successful,” said Maryland Insurance Commissioner Steven B. Larsen. “I think certainly it has provided an avenue for people to complain when care has been denied. As importantly, it sets up a process for medical review of those denials by HMOs.”
There were 1,526 complaints, in which consumers or health care providers said coverage was denied: 507 were outside the Maryland Insurance Administration’s jurisdiction, concerned Medicaid or Medicare or concerned employees covered by the Federal Employees Health Benefit Plan. Additionally, some of those 507 cases were referred to the Maryland Department of Health and Mental Hygiene, the Worker’s Compensation Commission or other state agencies.
Of the 1,019 remaining complaints, 17 were withdrawn, 71 contained insufficient information and 420 were found to have made no “adverse” decisions or “denials.”
“The number of cases in which we conduct a full investigation is a relatively small percentage of the whole,” Larsen said.
The administration investigated a total of 255 cases. Most of these cases fell under inpatient hospital stays, pharmacy services, mental health services, emergency room services and physician services. In 120 of these cases, the carrier reversed its initial denial.
“I am very pleased with the results of this year’s report,” said Larsen. “What we’ve shown is the appeals and grievance laws are working in Maryland. Inappropriate denials are being corrected and appropriate care is being delivered.”
The law, which the General Assembly revised last year, requires a person who is denied coverage based on lack of medical necessity receive a written “adverse decision” from the carrier within five working days of the decision. It also includes implementation of the Private Review Agent and certification of HMO medical directors. The agent reviews services to determine if they are medically necessary.
People who wish to challenge a decision made by their carrier must appeal through the health plan’s internal appeals process. Consumers are then able to file an external appeal with the Maryland Insurance Administration. The appeal includes a review by a medical expert to determine whether the procedure was medically necessary.
In case of an emergency, the consumer may go directly to the Maryland Insurance Administration.
“I think our judgment is that the process is working,” said Larsen. “And we have not received any complaints from the providers, expressing dissatisfaction with the process itself or the results that we’ve had.”
Mid Atlantic Medical Services declined to comment on the report and representatives for CareFirst BlueCross BlueShield could not be reached for comment. Nor could an industry lobbyist be reached for comment.