Report Cites Health Plan Errors And Denials

Attorney General Spitzer today released a report outlining the top consumer complaints concerning health care in New York State.

The single most frequently reported complaint involved errors by health plans in processing or paying claims (16.4 percent of all consumer complaints reported between July 2004 and June 2005). Over a third of all consumer complaints (36.5 percent) involved health plan errors in paying claims or approving care, and health plan denials of care or coverage for care.

Problems getting and keeping health insurance coverage because consumers were confused about their insurance options or could not afford health insurance accounted for 9.3 percent of all consumer complaints, making this the second most common complaint.

"New Yorkers continue to encounter numerous obstacles when accessing and utilizing health care services," Spitzer said. "Through enforcement efforts, advocacy, education, and legislative reforms the health care playing field can be leveled for health care consumers."

The 2004 and 2005 Health Care Helpline Report was compiled from more than 13,600 complaints received by the Attorney General's Health Care Bureau through its toll-free number in the 24-month period between July 2003 and June 2005. The report analyzes those complaints investigated by the office, explains enforcement actions, provides consumer tips, and suggests reforms to address systemic problems.

The report highlights a number of trends in comparing 2005 complaints to those analyzed in the 2003 report, such as:

  • Complaints regarding improper billing by providers increased from 13.2 percent to 16.2 percent of all consumer complaints;
  • Problems getting access to specialists and out-of-network care decreased from 21.9 percent to 13.8 percent of all consumer complaints.

In helping individuals address their health care complaints, Spitzer's office was able to recover approximately $4.2 million in additional care or coverage for consumers during the reporting period. Through various enforcement actions, the Health Care Bureau generated an additional $2.4 million in restitution for New Yorkers and $3.1 million in costs and penalties to the state.

The report also details the efforts of the Health Care Bureau to improve the experience of New York's health care consumers through education about their health care rights and benefits. During the period covered by the report, the Attorney General disseminated information about:

  • Maximizing health care benefits for the treatment of bulimia, anorexia and other eating disorders;
  • Steps that patients may take under state law to accept or refuse treatment and to appoint someone to make health care decisions for them when they become unable to make their own;
  • Accessing bariatric surgery and other treatments for obesity; and
  • The value of comparing retail prescription drug prices through the launch of , an interactive prescription drug price comparison website that helps consumers across the state find the best price in their community for commonly prescribed medications.

Finally, the report contains several recommendations to improve consumer access to health care and education. The recommendations include: fully funding New York's Managed Care Consumer Assistance Program; establishing statutory penalties for violations of the Managed Care Consumer Bill of Rights; adopting a standardized denial form for all health plan denials; and amending the Public Health Law and the Insurance Law to allow consumers access to the external appeals process to challenge denials of referrals to out-of-network providers.

Spitzer urged implementation of these reform recommendations to better protect and realize the rights of consumers that have already been established under New York law.

Consumers who want to file a complaint about their health coverage or who are looking for assistance with their health care plans or in obtaining health care coverage are encouraged to contact the Attorney General's Helpline at (800) 771-7755, option 3.

To obtain a copy of the Health Care Bureau's 2004-2005 Health Care Helpline Report, individuals are directed to visit the Attorney General's website:www.ag.ny.gov.

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