Illinois Hospital Association

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January 3, 2007

Attorney General’s Health Care Bureau Report on Top 10 Complaints

On December 29, 2006, the Illinois Attorney General’s (AG) Office released a report on the top ten health care complaints received by its Health Care Bureau in 2004-2005. The full report is available by clicking here.

The Health Care Bureau’s mandate is to protect and advocate for consumer rights and identify systemic problems with the health care system. They do so via: (1) operation of the health care hotline; (2) mediation of health care complaints; (3) investigations and enforcement actions when a pattern of misleading or deceptive business practice is identified; (4) consumer education; and (5) legislation and policy initiatives.         

According to the report, consumers most frequently contacted the Health Care Bureau to seek help in addressing billing errors by health care providers. The report does NOT specifically address hospital charity care and financial assistance issues. However, the Health Care Bureau has been designated to track complaints about these issues as well as to enforce violations of the new Fair Patient Billing Act (PA94-0885), which will standardize billing and collection practices for all Illinois hospitals. While the Fair Patient Billing Act went into effect on January 1, 2007, it applies to services delivered on or after July 1, 2007. PA94-0885 has four major components to be implemented by hospitals:

  • Patient notification about financial assistance

  • Bill information and inquiries

  • Collection practices and limitations

  • Notification of out-of-network providers.

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    Please take this opportunity to make sure your institution is implementing policies to address PA94-0885, as well as have an appropriate intake process for billing and collection issues. IHA previously provided members a memo regarding this law that is available by clicking here. The AG’s Office has said it will NOT issue rules for implementation of the new law.

    CONTENT OF REPORT
    According to the report, the Health Care Bureau opened approximately 2,100 complaint cases each in 2004 and 2005 and recovered approximately $1.7 million and $2.7 million in benefits respectively as well as a number of monetary penalties on a variety of firms.

    Consumers most frequently contacted the Health Care Bureau to seek help in addressing billing errors by health care providers (providers are not broken down by categories, i.e., hospital, professional). This type of complaint constituted 22 percent of the complaints received in 2004 and 27 percent in 2005. The most prevalent of these complaints concern billing the wrong amount or wrong code, while the remainder involve balance billing of health plan members by participating providers, processing errors, and the "usual and customary" bill or charge. The AG’s Office added 8 new complaint line items in 2005 on the billing issue: bill never received; provider will not remove bill from the credit bureau report; unknown bill; consumer requests refund from provider; fraudulent billing; refusal to issue an itemized bill; late fees and/or interest charges; and service never received.

    The second most common complaint involved claims processing and payment errors by insurance companies and health care providers. These complaints constituted over 18 percent of complaints in 2004 and 11 percent in 2005. These complaints typically arose when a health insurance company failed to process or pay claims, or paid the wrong amount or the wrong party. These complaints also involved health insurance companies making errors concerning the appropriate deductibles or co-payments allowed under the plan. The wrong diagnostic or procedure code and late filing of claims were the top claims processing/payment error issues. A new category of common complaint in 2005 is a dispute arising due to a plan-provider contract disputes. Specifically, the report cited cases of a provider not being paid the appropriate amount by a health care plan, with the consumer being billed during the dispute and "threatened with action by a collection agency."

    The third most common complaint that consumers raised with the Attorney General’s Health Care Bureau involved denials of care or coverage by health plans. These complaints fell into two broad categories: (1) medical necessity denials and (2) covered benefit denials. The report says that health plans erroneously issue denials and send bills to members claiming that a member or a provider has made an error or failed to provide information when, in fact, the plans are at fault for the error or lack of information.

    After the top three categories, the other top ten complaints concern: advertising; quality of care (dissatisfaction with a professional’s medical treatment or services); access to specialty care and out-of-network care; misinformation; problems obtaining and keeping coverage (policy terminated by employer and/or health plan); access to prescription drugs; and miscellaneous issues.

    TRENDS
    The report also highlights a number of trends in health care:

  • 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;

  • Increasing numbers of complaints about health plans underwriting short-term insurance policies several months after their effective dates and then denying claims and canceling the policies;

  • Consumers are being charged the out-of-network rates by insurance companies for services that the consumers did not understand were considered out-of-network.

    • CONCLUSION
    This report must be taken in context. The Illinois Division of Insurance (DOI) receives many more complaints than the AG’s Office about HMOs, individual and group accident and health insurance coverage: 5,733 in 2004 and 4,868 in 2005. However, your institution should be aware of the issues being mediated by the Health Care Bureau and prepare to address the new Fair Patient Billing Act. In addition, while provider issues were not specifically cited as a troubling trend in this report, we need to recognize those issues of concern to the public and work to alleviate them internally in our processes.

    IHA has worked closely with the AG’s Health Care Bureau to protect consumers and providers from certain types of egregious practices cited in this report, including enforcement actions taken by the bureau against discount health care companies that engage in deceptive marketing.

    Staff Contact: Elena Butkus: (630) 276-5526