Illinois Ag can help with healthcare complaints

[March 02, 2011]  As the business of medicine has become more complex, consumers have experienced more confusion and difficulty obtaining the care and benefits to which they are entitled. To assist the consumers of Illinois with these problems the Attorney General opened the Health Care Bureau in October 1998. Since then our staff has helped to clear up more than 8,000 complaints relating to health care issues.

Our intake workers take the complaint either verbally or in writing, and either open a mediation file or refer the consumer to the appropriate agency for assistance.

Mediators are trained in alternative dispute resolution and work directly by phone, fax, and letter with all parties involved in the dispute. Once a mediation file is opened, the mediator contacts the consumer to collect information and contacts the provider and/or insurance company to settle the dispute. Our success has resulted in savings of approximately 21 million dollars for the citizens whose claims we have mediated.

TO FILE A COMPLAINT

Fill out our Health Care Complaint Form (English)
Fill out our Health Care Complaint Form (Español)

Call our Hotline Number at 877-305-5145 or TTY 800-964-3013

HEALTH CARE BUREAU BI-ANNUAL REPORT
To learn more about the Bureau's complaint patterns and consumer tips related to health care issues, please visit the Health Care Bureau Bi-Annual Report.

Common Complaints include:

·         Denial of insurance benefits because prescription or treatment is considered any of the following : Not medically necessary, experimental or investigational, cosmetic, preexisting condition, not used according to FDA approved guidelines.

·         Slow pay on claims that may or may not result in damage to the consumer's credit history.

·         Claims partially paid leaving the consumer with an unexpected large balance to pay.

·         Denials of coverage for emergency services including emergency ambulance services.

·         Difficulty with access to primary or specialty physicians.

·         Billing disputes take many forms, such as fraudulent billing schemes and gross overcharging.

·         False or misleading advertising relating to health care issues.

·         Various problems involving the in-network versus out-of-network referral processes.

·         Difficulty with negotiating the internal or external appeals processes once a denial is issued.

When a pattern of misleading or deceptive business practice in health care is identified, the attorneys in our bureau can bring civil court actions to protect the consumers of the state. Additionally, three attorneys and a physician medical advisor are available to the mediators to assist with professional issues raised in the problem solving process.

Trying to Stay in Network to Maximize Your Insurance Coverage?

By now most of us are acquainted with lists of in-network doctors and pharmacies. Here are a few tips about staying in network that you may not know.

Most managed care plans have contracts with specific labs or x-ray facilities to provide services to their members. Check with your health plan customer service representative to make sure that the lab or x-ray facility you expect to use is currently contracted as an in networkprovider. This information is not always in your benefit brochures. Your doctor's office may be able to guide you but they frequently deal with 20 or more managed care plans and should not be solely relied upon to have the most current information for every plan.

If you use an out-of-network facility you will be responsible for all or a significantly larger portion of the bill. Lab and x-ray expenses can be substantial. It is a good idea to check with your health plan before scheduling and obtaining services whenever possible. After your doctor gives you a referral to see a specialist, always call your health plan to make sure that the specialist is currently in the network.

Most health plans have specific in-network ambulance companies. In-network hospitals may have x-ray, lab, surgical assistant and anesthesia services provided by out of network doctors who bill separately. Ask the hospital business office or the individual providers first so you know what to expect. If you must use out of network hospital based services that will cause higher bills for you, try to negotiate a price and payment plan before services are rendered.

Changes on the horizon in health insurance programs depend on an informed consumer actively involved in medical choices and managing their health insurance benefits. Ask for all of your policy documents, not just the marketing brochures, and read the fine print. Knowing the details of your coverage could save you thousands of dollars and lots of headaches in the future.

Health Care Bureau Hotline Number: 1-877-305-5145 or 1-800-964-3013 (TTY)

[OFFICE OF LISA MADIGAN< ILLINOIS ATTORNEY GENERAL]

Archived columns