By Christopher Guadagnino, Ph.D.

Published June 2000

• Act 68 regulations raise concerns
  

• React to this article in the Discussion Forum.

Lawrence M. Otter, Esq., is a senior deputy attorney general and the attorney in charge of the Pennsylvania Attorney General’s new Health Care Unit. Mr. Otter was formerly an assistant general counsel in the legal office of the Pa. Department of Health responsible for its Bureau of Managed Care

PND: Why was the Health Care Unit created and what are its functions?

LMO: Attorney General Mike Fisher’s Health Care Unit was officially announced to the public on Feb. 15 this year. We’re the sixth state to do this; the first one was New York’s Attorney General’s Office about three or four years ago and we’re basically modeled on what they do, utilizing Pa.’s version of the Unfair Trade Practices and Consumer Protection law. Prior to the creation of our Health Care Unit, the Bureau of Consumer Protection regularly got health care-related complaints. The Health Care Unit is specifically set up under that Bureau. When there’s some problem with payment for a health care service, the doctor or hospital may send out the bill to a collection agency and the health care consumer gets a dunning letter. We end up seeing that type of case. The Health Care Unit will help consumers get around barriers to proper health care, investigate and research cases where consumers are denied needed care or reimbursement, investigate unduly delayed payment by insurers for health care services provided and advise the Governor and the Legislature on consumer health care issues.

PND: What is the scope of authority of your office?

LMO: We’re empowered to mediate disputes in a fashion similar to what the Bureau of Consumer Protection normally does. We can take legal action on behalf of consumers against insurers and providers who engage in deceptive and unfair practices. If we see a pattern or practice by a health care entity, we’ll investigate that matter and, if need be, bring a civil action to stop it. There are other parts of the Attorney General’s office that can bring other types of actions, such as the Criminal Division. Pennsylvania recently passed the Fair Credit Extension Uniformity Act, SB 1038, dealing with debt collection practices. That clearly gave jurisdiction to the Attorney General’s office, since we were already doing that under our own separate regulations.

I was involved in the settlement of a case that started two years ago when Keystone Health Plan Central was marketing their managed care Medicare product. They were trying to get consumers to sign up and were talking about prescription benefits. An then, come January 1998, the prescription benefits evaporated or their copays went up, and premiums went up. That caused a lot of consternation among the senior citizens in central Pa. and the Lehigh Valley, prompted an investigation by our office and was ultimately resolved concurrent with the announcement of the Health Care Unit. Keystone signed an Assurance of Voluntary Compliance in which they agreed to reimburse consumers in eleven counties for some prescription costs and premium increases and paid for the investigation; the total was around $600,000. That deceptive practice—marketing a product while knowing that they would reduce and eliminate certain benefits—was something that led to the creation of this office.

PND: How can physicians use your office?

LMO: Our focus for the moment is solely with consumers, the providers’ patients. We’ll be happy to supply our brochure and complaint forms to doctors’ offices and, in fact, we’ve already received about 1000 calls from physician offices around the state asking for copies of those forms. They can give the form to the patient to fill out and sign. If payment delays, for example, can some how be fashioned as a consumer complaint, we’ll look into it, but the Insurance Dept. under Act 68 has clear authority to deal with that and we would probably refer it to them. I suppose if a physician made us aware of certain practices and procedures by a managed care entity that might violate some law, we would be interested. If there comes a time when we will clearly accept provider complaints, we will notify the medical and hospital community.

PND: Are there any plans to expand your focus to include physician complaints?

LMO: I’ll be taking that matter up with Attorney General Fisher at some time in the future. I would be in favor of handling certain types of health care provider complaints.

PND: What sort of consumer complaints does your office handle?

LMO: We will take a look at any complaint that is health care-related. If it clearly falls within our jurisdiction under the Unfair Trade Practices and Consumer Protection law, the Fair Credit Extension Uniformity Act or the Unfair Insurance Practices Act, we will handle it. If it turns out to be a licensure or regulatory matter, we immediately refer it out to the appropriate state agency like Health, Insurance, Welfare, Aging, Professional and Occupational Affairs, and to federal agencies such as Social Security and HCFA. In some cases we’ve even gone out and found private sector entities that would help a consumer in a certain situation. Between five and ten percent of our complaints get referred to other agencies.

PND: What issues fall within your jurisdiction, specifically?

LMO: Primarily billing issues, coverage denial issues, drug formulary problems, medical necessity questions, access to care issues, among others. For some of these issues we will work with other state agencies. We also ask consumers whether they have exercised their rights under Act 68. We recommend that they file a complaint or grievance pursuant to Act 68, but the Attorney General’s Office will also take the consumer’s complaint and concurrently attempt to mediate the dispute. In some instances, other state agencies have referred cases to the Attorney General’s Office. Recently the Department of Health referred a PPO matter to our Health Care Unit because neither Act 68 nor other legislation dealing with managed care gave jurisdiction to the Health Department for that type of entity. The original complaint was received by the Department of Insurance, who referred it to the Department of Health, who then referred it to the Attorney General. The Health Care Unit was successful in resolving this case, which involved an experimental treatment issue.

PND: How does your role fit in with Act 68?

LMO: We run parallel to Act 68. If you would view a grievance or a complaint filed with a managed care company as filing a lawsuit, if the person also files a complaint with us, we’ll be going down the settlement track that parallels the Act 68 process. A consumer can file both an Act 68 grievance or complaint and a complaint with the Attorney General’s Health Care Unit at the same time, but we specifically direct consumers to get on the Act 68 track also.

PND: Does your office have any enforcement authority over Act 68?

LMO: The enforcement authority is with the Health or Insurance Departments, but some matters that fall under Act 68 also fall under the Unfair Trade Practices and Consumer Protection law in Pennsylvania. So, there is parallel jurisdiction, in my view.

PND: How many complaints have you received thus far?

LMO: In three months we have received in excess of 300 in-hand, signed complaint forms. We’ve gotten in excess of 600 telephone calls on our hotline. About five percent of complaint forms we’ve received have been filed electronically. The top four categories of complaints that we’ve identified so far deal with issues involving HMOs, other health care insurance companies, hospitals and physicians. About half of the complaints deal with HMOs and insurance companies.

Our complaint form differs from the standard one used by the Bureau of Consumer Protection in that ours has space for provider information, medical insurance information and an authorization to release insurance and medical records because of confidentiality and privacy issues involved. On our hotline, if we get a call that is an emergency or an urgent situation, that case will be immediately assigned to an agent or sometimes an attorney and an agent, goes to the top of the pile and is worked on until it’s done. We’ve had some success with that type of case in resolving the problem in a matter of hours. In one case we got a managed care plan to talk to a drug and alcohol rehabilitation facility and agree to continue covering inpatient days for a potentially suicidal heroin addict who was about to be released. Through our contacts in the private, nonprofit sector, we also had arranged for contingency placement of the patient at another facility at no charge.

PND: How many of the complaints that you’ve received so far have been resolved or have led to legal action?

LMO: At least half of them have been resolved. For the cases that are pending, we have not had to go to court on any of them yet, but our agents have contacted the health insurance companies, hospitals or doctors about the complaints we have received.

PND: How do consumers find out about your office and obtain complaint forms?

LMO: Consumers can call our hotline number, 1-877-888-4877, or they can find us on the Internet, www.attorneygeneral.gov, and we are continually doing outreach with the Pennsylvania Medical Society, the Hospital Association and other health care-related groups who are spreading the word to their members and to Pennsylvania consumers. We would be happy to speak at any county medical society in the Commonwealth about our activities.