I came to realize the previous draft was lacking in at least two ways. It was focused on the mind-fucking Patient Protection and Affordable Charismatic Presidential Candidate Legacy Enhancement Act, for one thing. The focus on the soon-to-be repealed PPACA gave the whole letter a sour overlay of mootness.
Equally important, the letter as written probably wouldn’t have inspired the A.G. to take any action and didn’t set forth the specific action I was seeking. This one, I think, does better in those areas.
Here’s the rewrite, which is about as good as I can get it at the moment, After I post it I will go back to gnawing at my ankle:
January 4, 2017
Office of the Attorney General
Albany, NY 12224-0341
Honorable Attorney General Schneiderman,
I’m writing to alert you to a massive consumer protection failure in New York State and to encourage you to take action. There is no New York State agency where a citizen can pursue a claim of fraudulent denial of medical service against a health insurance company.
The need for state oversight is more important now than ever, with an incoming administration committed to dismantling government regulation in many areas.
I’ve admired the courageous and proactive steps your office has taken against the perpetrators of various frauds and urge you to consider this letter in the context of systemic healthcare-related fraud against a large class of vulnerable low-income and senior citizens of New York State.
Uncertainty about health care, lack of information about costs and the routine denial of medical services without explanation are all stressful. They negatively affect the health and quality of life of those mandated to participate in income-based “bronze” level health insurance plans in New York State. As detailed below, NYS health insurance buyers are denied any protection against the practices of private health insurance companies, even when the denial of necessary service appears to be utterly fraudulent.
This consumer protection emergency transcends the current health care scheme under the Patient Protection and Affordable Care Act (“PPACA”). The president-elect’s threatened repeal of the PPACA makes it all the more essential for New York State to regulate private insurance companies. The replacement for the PPACA, whatever it might be, will not eliminate the need for protection of vulnerable older and low-income consumers, the need will likely become even more pronounced.
In googling your mailing address to mail this letter I came across the New York State Health Care Bureau, a couple of layers down on your office’s website. While that office no doubt provides a welcome shoulder to cry on, the citizens of New York State sorely need a regulatory apparatus that can make timely and binding determinations on when insurance companies cross the line into actual fraud against their mandated customers.
Of course, the creation of a regulatory agency is a matter for the legislature. A fraud investigation by your office into practices such as the ones described below would highlight the need for state regulation, and give momentum to the legislative process.
As stated above, defrauded health insurance consumers (patients) in New York State have no forum where complaints can be resolved, outside of the NYS Department of Financial Services, which, it turns out, does not hear such complaints.
The fraud investigator there could not find a word other than fraud to describe the facts I set forth, but urged me to call the NY State Department of Financial Services Consumer Services Hotline. He assured me that they were the specialists in the area of health insurance. The recorded menu at the hotline, which I recognized from my first call many hours earlier, offers no option for resolving issues with insurance companies of any kind.
On my original call to the Department of Financial Services, a long wait to speak to a representative yielded the number of the proper federal agency to contact. Calls to the U.S Department of Health and Human Services are robotically routed to a NY State number that is, sadly, the office of Temporary and Disability Assistance, where some helpful party connects you to a fraud hotline, which turns out to be at the office of the Medicaid Inspector General, where the office of legal affairs is also sympathetic, but unable to help, and so forth.
As for the PPACA, I understand that it was drafted by Liz Fowler, a career health industry insider who went on to a senior executive position with Johnson & Johnson immediately after her work on the PPACA was done. I‘ve witnessed the many attempts to repeal the law and thwart its implementation, rather than fix any of its original flaws, as most other complicated laws are tweaked and improved over time. Even so, the lack of any provision for oversight of corporations participating in the PPACA by New York State is grotesque. To a sixty year-old cardiac patient unable to see a cardiologist now for many months, the lack of oversight may also be deadly.
Although the situation I’m complaining of is personal and extremely aggravating, it is sadly typical. I’ve commiserated with many others who suffer under similar insurance coverage. Erroneous bills are a common, if relatively innocuous, theme.
I receive bills that there is no way to resolve, most recently an invoice for $1,324 for a fully covered sonogram I had in August. The x-ray and kidney sonogram I also had that day were fully covered, the sonogram of another body part was not. The billing issue was resolved with the insurance company (Empire Blue Cross) and the provider to a zero balance in October. Two months later, the full bill for $1,342 was sent to me again in a Third Notice.
Nobody at Empire could give me the reason the provider had sent that bill, although the representative, who checked my account and called the provider again, informed me that, this time, it was my responsibility to pay it in full. She offered to send a consumer handbook for my plan that would fully explain the reason, which she claimed was clearly set forth there, though she could not state it.
There is nobody in New York State to adjudicate this billing matter, outside of a judge on some court one must file an actual lawsuit to appear before, assuming one could find a cause of action.
Empire recently sent me an email warning of termination of my insurance for non-payment of December’s premium two weeks after their email confirmation of my payment for December and January.
More ominously, a patient can be denied medical service without explanation (site-specific provider NPI numbers and proper CPT pre-authorization codes notwithstanding), and there is nobody in New York State you can appeal to, except to the company itself. Empire Blue Cross “Health Plus” recently sent me to two providers for needed medical services, a cardiologist and a physical therapy facility. Neither provided me with any service.
I received the site-specific NPI number for the cardiologist, scanned and emailed the back and front of my insurance card, got pre-approval from his office. The consultation was halted ten minutes in and I was informed that my insurance would not cover the visit. When I arrived at the nearby ‘physical therapy facility’ Empire had referred me to, it was a nursing home. The director told me the facility offers PT, but only to residents.
The circuit of government agencies I have contacted in vain came full circle with the “consumer help line” the NYS Department of Financial Services Fraud Unit investigator had me call, which I immediately recognized as the very first number I’d called. Here is a summary of that cul du sac:
NYS Department of Financial Services referred me initially to the US Dept of Health and Human Services which, supposedly, connected me to NYS Health and Human Services, although to an incorrect branch of that agency, the pertinent branch apparently having been merged into the NYS Department of Financial Services which took over all functions of the former NYS Insurance Department as well as oversight of banking and several other discrete* and seemingly unrelated areas.
The NYS Department of Financial Services, one learns, has sole responsibility for oversight of health insurance companies, as well as all fraud investigations related to consumer fraud against insurance companies, and complaints about the practices of banks and brokers. Everything but, according to John Marconi, a fraud investigator for the Department of Financial Services, investigations of colorable fraud committed by insurance companies against mandated health-care “consumers” in New York State.
My political and legal conclusions are beside the point. Whatever the reasons, the fact remains that in New York State in 2017, even under the PPACA, citizens whose health is menaced by private insurance company denials are denied any legal process to have these vexing, sometimes life-threatening situations resolved.
Outside of a possible Article 78 (which government agency would you sue for relief, the Department of Financial Services?) or a class action under a private attorney general or qui tam statute, what is a patient trying to get an appointment to see a cardiologist since August to do under the Patient Protection Act in New York State? At minimum an ombudsperson, or a few hundred of them, would be a good start.
As I stated above, I’ve followed your career from the start and have admired your principled engagement in the fight against injustice. To have a legal right that cannot be enforced is to have no legal right. While certain widespread injustice is accounted by some as a kind of ‘externality’, the lack of legal recourse for denial of purchased health care must not be allowed to stand in New York State.
I will be glad to do what I can to help your office take the first steps towards sorely needed due process for denial of health care for some of the State’s most vulnerable citizens. I am open to being a plaintiff in any lawsuit the State might want to bring and to testifying in any proceeding. I look forward to hearing from your office and stand ready to give any other details or assistance your office might require.
* teachable moment! The previous draft had idiotically read “discreet”, an error imperceptible to homophone-deaf smell check