State insurance commissioner actions against health maintenance organizations for denial of emergency care

Abstract

Objective. Concerns have emerged from two west coast communities that health maintenance organizations (HMOs) may deter their members from calling 911. One means of influence is retrospective denial of emergency department (ED) or emergency medical services (EMS) claims. The study objective was to systematically assess legal action taken to contest HMO denial of claims. Methods. Telephone survey of all state insurance commissioners (SICs). The specific question asked was: “What actions, if any, have been taken by the Office of Insurance Commissioner since 1990 against HMOs for denying claims for emergency department care or care provided by paramedics after a person has called 911?” Each office was contacted at least three times. Results. Representatives from 49 states were interviewed. Three states (6%, Oregon, Texas, and Virginia) have taken formal action since 1990. Oregon fined two HMOs a total of $25,000 for inappropriate systematic claim denial of ED care. Texas fined one HMO $1,000,000 for similar practices. Virginia, with no authority to fine, has issued citations. No action had been taken for denying EMS claims. Thirty-eight states (78%) reported no formal actions. Eight (16%) state SICs could not easily retrieve these data and did not report. Fourteen (29%) representatives reported receiving these complaints. Most of these complaints were resolved without formal SIC action. Conclusions. Three health plans in two states received financial penalties for systematic denial of ED claims. A fourth was cited. This may underrepresent the true incidence of appealed ED and EMS claim denials. While complaints occurred in 29% of states, recent actions by SICs are relatively rare (6% of states). These results speak more to the extent systematic claim denials are discovered by SICs than to the true incidence of this practice.

Key Words:

• health maintenance organizations
• EMS
• emergency department
• insurance
• medicolegal
• state insurance commissioner
• denial of care.