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Right to appeal rejected claims praised by state officials Process effective Jan. 1 helps patients fight back; Health insurance


Top state officials praised Maryland's new appeals process for health-insurance customers yesterday, saying the system gives patients additional tools to fight back when HMOs refuse to pay for doctor-prescribed care.

A law taking effect Jan. 1 requires insurers that reject medical claims to let patients know they can protest the decision and seek help from the Maryland Attorney General's office. It also gives patients the ability to have a case reviewed by independent experts.

While several other states have health-insurance appeals processes, "Maryland's is very consumer-friendly" in its disclosure provisions, said Maryland Insurance Commissioner Steven B. Larsen.

Maryland has had a health-advocacy unit since 1987, but "we were a secret," said Attorney General J. Joseph Curran Jr. "Only by word of mouth did people know about us."

Now, Curran added, patients "will no longer have to take 'No' for an answer. We will help them negotiate with the insurer for a more favorable resolution."

As part of the campaign to get out the word, Curran and Larsen held a news conference yesterday to talk about the new law.

The changes, passed by the General Assembly this year, grew out of complaints by doctors, hospitals and patients about rejected claims by health maintenance organizations and other insurers. Insurers are required to pay for "medically necessary" care, but critics charge that the companies have been increasingly rejecting needed procedures to save money.

The law affects only about half the 3.5 million Marylanders with private health insurance. People working for self-insured employers aren't covered.

Maryland insurers supported the law, saying it provides a faster, cheaper way of resolving insurance disputes than lawsuits.

The law requires insurers to have their own appeals procedures for denied claims, and the Attorney General's Health Advocacy Unit is available to assist that process. If no satisfaction is reached, patients or health providers can then complain to the Maryland Insurance Administration.

Using independent medical experts, the insurance administration may agree with the insurer's denial or may order the insurer to pay for the disputed treatment.

"We've hired the staff. We now have a physician on staff. We're upgrading our phones," Larsen said. Plus, he added, physicians and hospitals "are engaged in their own very active education campaign."

Consumers with questions about the new law or complaints will be able call the Health Advisory Unit at 1-877-261-8807 -- but only after Jan. 1, officials said. The Insurance Administration's toll-free number is 1-800-492-6116.

Pub Date: 12/22/98

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