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Annual Report Reveals Health Insurance Denials Are Rarely Challenged, but Appeals Are Often Successful
BALTIMORE, MD – Attorney General Anthony G. Brown announced today that his Health Education and Advocacy Unit (HEAU) within the Consumer Protection Division of the Office of the Attorney General closed 2,068 complaints in Fiscal Year (FY) 2025, assisting patients in saving or recovering nearly $2.6 million dollars, including more than $1.6 million in appeals and grievances cases. The information was included as a part of the comprehensive FY 2025 Annual Report on the Health Insurance Carrier Appeals and Grievances Process that is submitted to the General Assembly each year.
The HEAU offers mediation services to consumers facing issues such as private health insurance, medical billing concerns, hospital financial assistance applications, medical debt collection, and access to medical records. The HEAU also helps consumers who have problems enrolling in a private health plan on Maryland Health Connection, the state’s health insurance marketplace, or with obtaining financial assistance to lower the cost of coverage.
“Marylanders shouldn’t have to navigate the health care system by themselves when they get a confusing medical bill or their insurance denies them coverage,” said Attorney General Brown. “That’s where our Health Education and Advocacy Unit comes in: we level the playing field and help Marylanders get the medical care they need, the coverage they have paid for, and the financial assistance they are entitled to.”
Key Findings
The HEAU Annual Report reflects that denials of coverage happen routinely without being challenged. In fact, according to carrier-reported data over the last 10 fiscal years, on average, only 10% of adverse decisions were challenged, and on average 55% of those denials are reversed when challenged. Given the low number of grievances filed and the likelihood of a positive outcome when a grievance is filed, consumers who are denied coverage are urged to seek help from the Health Education and Advocacy Unit.
Mediation of Appeals and Grievances
Of the cases closed by the HEAU in FY 2025, the HEAU mediated 449 appeals and grievances-related cases. As a result of the HEAU mediation process, 52% of the medical necessity cases, 47% of the coverage decision cases, and 57% of the eligibility denial cases were overturned or modified. When the original denial is not overturned or modified, the HEAU is often able to negotiate a reduction in the billed fee from the provider and set up reasonable payment plans for consumers.
FY 2025 Case Examples
In one case mediated by the HEAU, a consumer was experiencing severe back pain that required surgery. The pain was so intense that he relied on narcotic medications, which impaired his ability to function. His carrier denied coverage for the surgery, finding it not medically necessary. After internal appeals with his carrier failed, the HEAU submitted an external appeal to the Maryland Insurance Administration (MIA). The denial was overturned by an independent medical reviewer, the consumer received the necessary surgery, and has since reported significant physical improvement and better quality of life. To watch this consumer’s story, click here.
In another case mediated by the HEAU, a consumer was admitted to the hospital for a tongue laceration. During the hospital stay, the consumer also experienced alcohol withdrawal and was treated for both conditions. A supplemental insurance carrier denied coverage of his care, claiming an exclusion in the policy prevented coverage if the patient was admitted while intoxicated or under the influence of drugs. However, the consumer was not under the influence of drugs or alcohol at the time. The HEAU intervened, challenging the denial, and the carrier ultimately reversed its decision, saving $12,000 for the consumer.
Surprise Medical Bills
The HEAU also assists consumers faced with surprise medical bills, which has been a persistent problem for consumers in Maryland and nationwide. The No Surprises Act, which became effective January 1, 2022, established new protections from surprise billing and excessive cost sharing for consumers receiving out-of-network healthcare items and services in emergency situations and while at in-network facilities.
In one recent No Surprises Act case, a pediatric consumer was transferred from the emergency room to inpatient psychiatric care within the same hospital – just two floors apart. While the rest of the hospital was in-network, the psychiatric unit was out-of-network, a fact that was not disclosed to the consumer’s parent at the time of transfer. The claim for services was processed by the carrier as out-of-network, requiring the family to meet their $10,000 out-of-network deductible and other out-of-network cost sharing obligations, rather than as in-network as required by the No Surprises Act. The HEAU intervened, challenging how the claim was processed; all claims were ultimately processed as in-network, saving the family $23,500.
Medical Billing Disputes
The HEAU also helps consumers with medical billing disputes. In three recent cases, consumers responded to television advertisements offering free consultations or trials at erectile dysfunction clinics. Each was asked to sign loan applications during the consultation – often without adequate explanation of the terms or copies of the documents. When the consumers decided against treatment or were unable to obtain the treatment because the clinic closed, both the clinics and lenders refused to cancel the loans. The HEAU intervened in all three cases, saving consumers a combined $17,000.
Consumers seeking assistance from the Health Education and Advocacy Unit can call the Unit’s Hotline Monday to Friday, 10 am to 2 pm, at 410-528-1840 (en español: 410-230-1712) or file a complaint online at www.MarylandCares.org.
Copies of previous years’ reports can be found here.
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