WASHINGTON -- When Jacqueline Lee went hiking in the Appalachians, she didn't bargain on slipping on a moss-covered rock, cracking her head and tumbling unconscious down a 40-foot cliff in a fall that broke her skull, arm and pelvis.
But perhaps even more shocking was when the University of Virginia Medical Center sued her because a health insurer refused to pay the hospital for putting her back together.
"The HMO denied coverage because I didn't get pre-authorization," said Lee, 28, of Bethesda. "Apparently being unconscious is not an excuse."
Eventually freed from legal troubles after the Maryland Insurance Administration intervened and forced her HMO to pay $10,000 in outstanding medical bills, Lee spoke yesterday at a panel held by the National Association of Insurance Commissioners (NAIC).
An umbrella organization for state insurance regulators, the NAIC launched a public relations drive to assure Americans that they shouldn't feel powerless when they have complaints about health insurance providers, and that they can turn to the states for help. "We'll roll up our sleeves and go to bat for the consumers," said NAIC President Glenn Pomeroy, North Dakota's insurance commissioner.
The drive is part of a two-pronged approach by state regulators to refashion their role in the era of managed care. In addition to making themselves more accessible to consumers, the regulators -- emboldened by beefed-up laws in some states -- are responding to complaints by going after recalcitrant insurance providers in new ways.
"I don't think any of us are here to do HMO-bashing," said Steve Larsen, commissioner of the Maryland Insurance Administration. "This is a recognition by state policy-makers and regulators that, with the transition to managed care, we need to rethink the role of regulation."
Larsen described how a controversial Maryland state bill -- which was signed in May and becomes effective Jan. 1 -- allows his agency to respond to valid complaints by revoking the certificates of HMO medical directors, by re-evaluating how providers review claims, and by getting involved earlier in limited cases, often as soon as a claim is denied. Maryland is known for having some of the stiffest HMO regulations in the nation.
States can regulate most HMOs and insurance companies. Most self-funded benefit plans, however, fall under federal jurisdiction, where recourse is often federal court. Nationwide, 77 million Americans are in plans under state jurisdiction. In Maryland, about 3 million consumers have plans covered under state law.
Larsen also said that state lawmakers approved $200,000 in additional funding for the current fiscal budget year for his agency to respond to complaints.
The NAIC projected yesterday that state insurance departments will receive 35,000 complaints from Americans about their health insurance in 1998. Since the NAIC never kept track of numbers in the past, it is unclear whether the transition to managed care is increasing complaints.
Donald White, spokesman for the American Association of Health Plans, an HMO trade group, stressed that HMOs handle most complaints themselves. "HMOs have always been minimizing disputes and resolving disputes," he said. "This is one of the advantages of being in an HMO or in managed care."
Pub Date: 9/10/98