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Post date: November 22 2002

New Report Cites Shortcomings Of State's Health Care System

Attorney General Spitzer today released a report listing the top complaints New York consumers have about the state's health care system.

The report notes widespread confusion about health plan policies and shows that consumers often settle for inadequate health care or coverage for that care because they do not know how to challenge coverage decisions made by their health insurance companies.

"Informed consumers are empowered consumers," Spitzer said. "Time and time again, we find that consumers who know their rights and who challenge health plan denials of care and question bills from health care providers make out better than those who simply accept what is offered."

The report was based on a review of almost 9,000 consumer complaints received over the last year-and-a-half by the Attorney General's Health Care Bureau, which operates a toll-free health care "helpline" that assists consumers in dealing with health care problems.

According to the report:

  • Most consumers who called the helpline expressed some degree of confusion and frustration about the health care system;
  • 30 percent of complaints involved mistakes by health plans and health care providers in preparing, processing or paying claims;
  • 23 percent of complaints involved health plan denials of care or coverage for care, including care that consumers believed to be medically necessary;
  • 19 percent of complaints involved problems getting or paying for specialty care;
  • 15 percent of complaints involved getting or keeping health care coverage;
  • 10 percent of complaints were prompted by improper billing of consumers by providers; and,
  • 4 percent of complaints were about access to prescription drugs.

Spitzer said the key consumer tip for dealing with these and other problems is to learn about the health plan's grievance and appeal process. Generally, very few people who are denied care file an appeal, but most of those who do appeal win more care, he said.

The report also makes a series of recommendations to help reduce confusion on the part of consumers and to help resolve consumer disputes with their health plans and providers, by:

  • Expanding the state's Elderly Pharmaceutical Insurance Coverage (EPIC) program to include Medicare participants with disabilities who are under age 65;
  • Allowing consumers to appeal to an external reviewer their health plan's denials of referrals to out-of-network specialists;
  • Providing statutory penalties for violations of the Managed Care Consumer Bill of Rights;
  • Mandating a consumer-friendly model claim denial notice for use by all health plans; and,
  • Fully funding the state's Managed Care Consumer Assistance Program.

Richard Kirsch, Executive Director of Citizen Action of New York said: "This report provides vital information that we can use to help individual consumers and to improve the health care system for everyone. We commend the staff of the Attorney General's office for all the valuable work that it has done to protect consumers, especially the Helpline staff who are literally on the front line helping consumers every day."