One of the region's largest health maintenance organizations has agreed to pay nearly $250,000 in medical expenses for an Ellicott City boy who was treated outside the HMO's network and whose bills the HMO initially refused to pay.
The Maryland Insurance Administration said yesterday that the reversal is one of the largest it has obtained.
Last week, NYLCare Health Plans of the Mid-Atlantic Inc. waived its right to contest the charges at a hearing and agreed to pay $244,512.50 for the boy's inpatient treatment at the Kennedy Krieger Institute in Baltimore for a rare digestive disorder, an additional $5,085 for his outpatient services, and a fine of $1,000.
The patient, Justin Helwig, 13, has multiple disabilities and medical conditions, including mental retardation. NYLCare said it made a mistake in denying care to the boy, but the incident could have been avoided if his parents, Stephen and Peggy Helwig, had formally appealed the decision.
"This is not a finding against us," said Jeff D. Emerson, NYLCare's president and chief executive. "We agreed to pay it.
"We didn't quarrel. We didn't go to hearing. We didn't ask for weeks to study it. We didn't litigate it. We paid it."
Emerson said a "subcontractor" with the managed care company originally denied the payment for care that Justin received in 1996 and 1997 because Kennedy Krieger is not in the HMO's network of providers. When NYLCare was alerted by the insurance administration in March that it was being ordered to pay, a company official "concluded it was something we should cover," Emerson said.
NYLCare has about 500,000 subscribers in Maryland, and 77 hospitals and 14,120 physicians in its mid-Atlantic network. Blue Cross Blue Shield insures about 1.4 million Marylanders.
One of the most contentious issues in the case is whether the Helwigs and Kennedy Krieger appealed the initial decision by the company to not pay the medical costs.
Emerson said the parents and the hospital did not appeal. According to the judgment order by the insurance administration, the hospital appealed NYLCare's decision in November 1996, when Justin began treatment there.
And the Helwigs appealed in their own way, they said.
"We begged NYLCare," said Peggy Helwig, who filed the complaint with the insurance administration in December 1997. "In letters and phone calls from us and doctors, we asked them to please let our child go to Kennedy Krieger. We let them know this was our only ray of hope.
"They made a very poor judgment call," said Helwig, who also has an adult daughter with her husband Stephen.
The case is a look at what can happen when a managed care company exercises its right to not pay bills incurred by clients -- or authorize treatment -- at facilities not in its network of hospitals and doctors.
"This is clearly an issue society is trying to deal with in terms of access to health care," said Nancy Fiedler, senior vice president of the Maryland Hospital Association, a coalition of the hospitals in the state that often deals with HMO payment issues.
"The insurer is primarily concerned with managing costs effectively. And the patient is more concerned with getting access to health care," she said. "And then we have the insurance administration trying to be the arbiter."
The issue began in October 1996, when a team of doctors determined that the only facility in Maryland that had the capability to treat Justin's complex digestive disorder was Kennedy Krieger Institute, said Steven B. Larsen, the insurance commissioner.
He began treatment at the hospital in November of the same year.
At that time, Justin had no digestive capability and weighed 47 pounds. He received seven months of inpatient care at Kennedy Krieger, and then had a nine-month interruption in his care because NYLCare also refused to pay for outpatient services, the Helwigs said.
Justin began his outpatient care in March after the Helwigs left the NYLCare plan and enrolled with another health care provider. Currently, the boy can eat only if he's placed in a specially designed chair and hand-fed his food after it's chopped or pureed, the Helwigs said.
In March, the insurance administration found that NYLCare had violated the terms of its contract with the Helwigs and provisions of Maryland law. Because the state's medical assistance program compensated Kennedy Krieger, under the settlement, NYLCare will reimburse the program.
The insurance administration has not kept track of what health care providers in the state have had multiple complaints against them, said Larsen. A computer system that was installed last month will began tracking such trends.
Thousands of complaints are forwarded to the administration a year, he said. In about half of the cases, companies are ordered to pay or they pay voluntarily.
Pub Date: 5/27/98