Press Release

For Immediate Release
Contact: Cara Smith
312-814-3118
877-844-5461 (TTY)

csmith@atg.state.il.us
December 29, 2006

MADIGANíS HEALTH CARE BUREAU ISSUES FIRST REPORT OF TOP TEN HEALTH CARE COMPLAINTS

Chicago – Attorney General Lisa Madigan released a report outlining the most frequent complaints received by her officeís Health Care Bureau in 2004 and 2005.

The Attorney Generalís Health Care Bureau protects and advocates for the rights of health care consumers statewide by addressing complaints and health care consumer problems through mediation and dispute resolution, education, legislation, and law enforcement actions.

During these years, the Attorney Generalís Health Care Bureau received approximately 5,058 complaints through its toll-free hotline, letters and e-mails. The Health Care Bureau Report analyzes the complaints mediated by the office, describes enforcement actions taken and provides tips to consumers to avoid some of the most frequent problems. In 2004 and 2005, Madiganís office obtained over $4.5 million in additional care or coverage for consumers. Without this assistance, consumers may have paid for health care costs that should have been covered by their health plans.

According to the report, consumers most frequently contacted the Health Care Bureau to seek help in addressing billing errors by health care providers. This type of complaint constituted 22 percent of the complaints received in 2004 and 27 percent of the 2005 complaints. Most often, these complaints involve situations in which the provider has billed the consumer for the wrong amount or using an incorrect billing code. In other instances, these complaints involve balance billing of health plan members Ė billing the patient for an amount over what the insurance company pays Ė and processing errors by physicianís offices, hospital billing departments, diagnostic facilities and other health care providers. The lawyers, mediators and staff of the Attorney Generalís Health Care Bureau assist consumers to sort out and obtain corrections of these often very costly errors.

The second most common complaint involved claims processing and payment errors by both insurance companies and health care providers. These complaints constituted over 18 percent of complaints in 2004 and 11 percent in 2005. These complaints typically arise when a health insurance company fails to process or pay claims, pays the wrong amount or pays the wrong party. These complaints also often involve health insurance companies making errors concerning the appropriate deductibles or co-payments allowed under the plan. In a number of instances, health care providers are the cause of these errors because they have filed claims late with the insurance companies or failed to provide the insurer sufficient information to assess the claim.

The third most common complaint that consumers raised with the Attorney Generalís Health Care Bureau involved denials of care or coverage by health plans. These complaints fall into two broad categories: (1) instances where health plans deny coverage by stating that a medical service is cosmetic, custodial or experimental and, thus, not medically necessary; and (2) instances where health plans deny coverage by stating that a service is not a covered benefit (in these instances, health plans often assert that the consumer has reached the benefit maximum under the plan or that the treatment involves a ďpre-existing conditionĒ).

The report describes these complaints in detail and highlights a number of trends in health care, including:

  • The uninsured are increasingly turning to alternative products such as discount medical cards to provide relief from the high cost of medical care. These products often lead to a number of problems for consumers and, as a result, the Health Care Bureau has filed suits against two medical discount card companies.
     
  • A number of consumers who have health insurance are experiencing coverage problems due to erroneous health plan coverage adjudications and overly broad interpretations of policy exclusions.
     
  • The Health Care Bureau has seen an increase in complaints that concern health plans underwriting short-term insurance policies several months after their effective dates and then denying claims and canceling the policies.
     
  • The Health Care Bureau has received numerous complaints from consumers who were charged the out-of-network rates by insurance companies for services that the consumers did not understand were considered out-of-network.

To assist consumers in addressing common health care consumer problems, the report provides a number of tips for consumers.

In general, consumers who need assistance with a health care related issue or who want to file a complaint about such an issue should contact the Attorney Generalís Health Care Bureau Hotline at 1-877-305-5145 (TTY: 1-800-964-3013).

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