Health Education and Advocacy Unit,
Maryland Attorney General’s Office

This program provides consumers with expert guidance through the process of pursuing health insurance appeals and with other health-related insurance and billing issues.

Program Structure and Services

The Health Education and Advocacy Unit (HEAU) was established in 1986 as part of the Consumer Protection Division within the Maryland Attorney General's Office. The HEAU helps consumers whose health plans have refused to cover medical services or to pay for medical care that has already been provided. The program also mediates billing disputes that consumers have with hospitals, other health care providers, and medical equipment providers; helps consumers negotiate refunds on medical equipment that is defective or was never delivered; and helps patients get repairs for medical equipment and other health care products. The HEAU often uses mediation to resolve consumer complaints.

The HEAU operates a hotline with four full-time staff members. Interns and volunteers, many of whom are retirees from the medical field or insurance industry, are also an integral part of its operations. The HEAU uses a database to track its cases, streamline the appeals process to meet appeals deadlines, and generate letters to request or submit appropriate information related to appeals or other casework.

The HEAU has developed an effective partnership with the Maryland Insurance Administration, which helps it identify larger issues in health care appeals policy and enforcement. The HEAU refers cases to the Insurance Administration when they are not successfully resolved through the insurer's internal appeals process. The HEAU also refers cases to the appropriate professional, licensing, or disciplinary body when a billing or coverage question concerns the quality of any services or treatment.

Maryland has several laws on the books that have enhanced HEAU's ability to assist consumers. For example, insurance carriers must respond to the HEAU’s requests for information within seven days. Maryland insurers must also provide information about the HEAU to consumers with their Explanation of Benefit forms (EOBs) or other determination of benefits correspondence. Maryland insurers are required to submit quarterly data to the Insurance Administration regarding the number of adverse decisions they issue. The HEAU summarizes these data in a publicly available annual report that also includes the HEAU’s evaluation of the effectiveness of the internal grievance and complaint process that is available to consumers.

Using experience from the HEAU's casework, Maryland has also strengthened its appeal rights laws. For example, when insurers deny claims, they have to issue their decisions to consumers in writing, provide an explanation of the reason for the denial, and give clear directions for how to file appeals and seek help through the HEAU. Some of these longstanding features of Maryland’s appeal system are now part of federal grievance and appeal rules.

HEAU’s operation as an independent entity, separate from the Maryland Insurance Administration, also has important benefits for consumers. For example, the HEAU can assist consumers even when their disputes do not fall under the jurisdiction of the Insurance Administration or other state regulatory agencies, such as consumers in self-funded employer health plans. HEAU’s independence also makes it easier for consumers to approach than a multi-service government agency or their health plan. The HEAU’s outreach coordinator explained that “Outside help is important, usually clients do not feel they have enough information, are afraid to try to address issues on their own, or don’t believe they will be successful. When a third party is involved, vendors are generally more responsive…they see that a client is prepared to seek assistance.”

Of the 1,610 cases the HEAU closed in the 2010 calendar year, the HEAU recovered more than $1 million for consumers in insurance-related cases.

How Did Consumer Assistance Grant Funding Help the Health Education and Advocacy Unit?

Maryland's consumer assistance grant of $642,151 enabled the HEAU to hire additional staff and assist more consumers with the grievance and appeals process. The HEAU hired a deputy director to help manage staff and oversee casework, two additional health ombudsmen, and an outreach coordinator. The grant also required the HEAU to formalize the enrollment assistance it had previously been doing on a more informal basis. The HEAU's enrollment assistance now includes educating consumers about available coverage options, providing resources to help with plan selection, assisting consumers with filling out enrollment applications, and helping consumers with coverage transitions (such as recently unemployed consumers who are eligible for COBRA coverage).

Program Education and Outreach

To expand its capacity to advertise the new services it offers, the outreach coordinator has developed new public education materials, distributing them directly to health care consumers through their providers, support groups, employers, and other routes. The HEAU continues to investigate other ways of communicating its services to consumers, such as mass transit and radio advertising. Over the past year, the HEAU has seen an increase in the number of cases and has handled a significant number of complaints from consumers who have been denied coverage based on pre-existing conditions.

Consumer Story

One consumer contacted the HEAU when her application for an individual policy in the private market was denied based on an erroneous claim by the insurer that the consumer had a history of liver disease. The consumer contacted the HEAU, and an ombudsman helped her appeal the insurer’s decision, gathering medical records going back seven years showing that she had not received a diagnosis of liver failure, nor had she had any diagnostic testing or treatment related to liver disease. The insurer reconsidered its decision based upon the additional documentation and offered the consumer a policy.

Sources

• Interview between Cheryl Fish-Parcham and Elaine Saly, Families USA, and Adrian Redd, Ombudsman, and Sharen Snelham, Outreach Coordinator, Health Education and Advocacy Unit, Maryland Office of the Attorney General, June 22, 2011.
• Health Education and Advocacy Unit, Consumer Protection Division, Office of the Attorney General, Annual Report on the Health Insurance Carrier Appeals and Grievances Process (Baltimore: Office of the Attorney General, 2009), available online at http://www.oag.state.md.us/Consumer/HEAUannrpt09.pdf.
• “Overview of the Health Education and Advocacy Unit,” presentation at Families USA’s 2009 Health Action Conference by Ellen L. Kuhn, Assistant Attorney General, Maryland Office of the Attorney General.

PDF of this profile is available.