WASHINGTON – Marylanders trying to appeal their insurance company’s denial of their health claims have a state agency to help them.
But until recently, it got very little attention.
The health insurance ombudsman, created by the General Assembly in 1986, has gained prominence only in the past two years, as increased funding and new laws requiring insurance companies to tell consumers about the office have boosted its business.
What started as a small part of the attorney general’s office, with one ombudsman and a director, has grown in the last two years to include four ombudsmen, a secretary, a director, and a program director. A second secretary is expected to be hired soon.
“The caseload has really picked up this year,” said program director Sammie Mouton.
The office’s hotline now receives 50 to 60 calls a day, about 85 percent of which are possible cases, said ombudsman Adrian Redd. That’s in addition to the letters and the walk-in visits to the ombudsman’s Baltimore office.
Ombudsman now deal with about 120 cases at any given time, a caseload that has caused the office to rely more heavily on its 20 to 25 trained volunteers and interns.
“Many of them have training as pharmacists and other health professionals, so they can handle some of the cases,” Mouton said.
In fiscal 2000, the office closed 2,083 cases, a 150 percent increase from the year before. Indications are that the caseload will continue to grow in fiscal 2001.
The success of the program was cited during Senate hearings last week on a bill funding ombudsman programs, when the Maryland program was held up as an example for other states.
Bernadette Warren, of Upper Marlboro, testified that the Maryland office was able to help her get insurance for a friend when “I couldn’t get help anywhere else.”
“I got their help and thank God they were there,” said Warren.
Consumers are not the only ones with praise for the ombudsman’s office. Insurance companies, who help pay for the operation of the office, said the office helps smooth out problems between them and their customers.
“It gives an avenue for resolution short of having to go to court,” said Jim Day, spokesman for CareFirst BlueCross BlueShield. “The benefits we get out of it probably make the price of it worthwhile.”
Insurance companies are required to pay into a fund for the ombudsman’s office, based on their share of the market in Maryland. The money goes to salaries for the office director and three of the four ombudsmen. The rest of the office’s funding comes from the state.
Walter Cherniak, spokesman for Aetna Inc., said Aetna supports the ombudsman’s office.
“It’s important that consumers have all the information they need and that they know their rights. We want them to understand their plans,” he said. “We’d support anything that helps them do that.”
The ombudsman’s office is part of the attorney general’s office, but it does not get involved in litigation and has no regulatory authority. It helps consumers understand their health bills and insurance coverage, identify improper billing or coverage decisions and mediates disputes between consumers and insurance companies.
Its primary purpose is to help consumers appeal an insurance company decision denying a claim. Cases tend to take a month or less. If nothing can be worked out with the insurer, the ombudsman steps aside to let the Maryland Insurance Administration take over.
“At this point, our relationship is working very well,” said Joy Hatchette, associate commissioner for consumer complaints at the insurance administration. “Consumers are pleased you can go from one agency to another without a problem.”
The administration is not involved in the 25 percent of the ombudsman’s cases with self-insured plans, which fall under the federal Employee Retirement Income Security Act of 1974 (ERISA). But the ombudsman office can still help these consumers by working with the federal agencies, just as it does the insurance companies.
“Our assumption is that the denied treatment is needed, and that’s how we proceed,” Redd said.
Officials said the ombudsmen work mostly by phone and through the mail to try to come up with the best solution for all parties.
“It’s very rare that we meet our consumers,” Mouton said.
But she said the office is very effective at helping consumers: A fiscal 2000 report by the agency showed that 51 percent of consumers were able to challenge insurance decisions successfully, but 76 percent got a decision modified or overturned when the ombudsman was involved.
There are times when the ombudsman cannot help, but the office will try to provide general health information to consumers or refer them to someone who is better able to assist them.
“We will deal with any health-related issue. Requests run the gamut,” Redd said. “If we can’t help, we see if we can refer them to the appropriate party.”