Top consumer complaints about health care in New York State

Attorney General Eliot Spitzer has released a report outlining the top consumer complaints about health care in New York State.

The 2003 Health Care Helpline Report was compiled from nearly 7,800 complaints received by the Attorney General's Health Care Bureau through its toll-free helpline during a twelve-month period between July 2002 and June 2003. It analyzes those health care-related complaints investigated by the office and issues proposed reforms to address systemic problems.

"The report indicates that too many consumers need assistance when navigating the complex world of health care and in protecting their rights," Spitzer said. "This report also demonstrates that consumers from across the state would be well served with full financial support for the Managed Consumer Assistance Program enacted in 1996 to help individuals gain information about and access to health care."

At least one-forth of all consumer complaints to Spitzer's Health Care Bureau arose from health plan or provider mistakes in claims preparation, processing and payment, and almost two-thirds of those mistakes are attributable to health plans. These types of complaints have remained the most common health care complaint since at least 2001.

Access to specialty care and out-of-network providers accounted for nearly 22 percent of all consumer complaints, making it the second most-common complaint.

The report highlights two noteworthy trends in 2003 Helpline complaints as compared to complaints analyzed in the 2002 report:

• Denials of care or coverage by health plans decreased from 23.2% to 17.4% of complaints; and
• Denials of emergency care by health plans declined from 1.2% to 0.6% of complaints.

While observing these trends, the report notes that its sample size is limited and that the 2003 Helpline report covers a 12-month period compared to the 18-month period covered by the 2002 report.

In assisting individuals in addressing their health care complaints, Spitzer's office was able to recover $3.9 million in additional care or coverage for consumers in 2003. Through enforcement actions, the Health Care Bureau generated an additional $862,000 in restitution for New Yorkers and $344,500 in costs and penalties to the state.

The report also contains recommendations to improve consumer access and satisfaction with the state's health care system by:

• Mandating use of a model claim denial notice by all health plans to address inadequate and confusing denial notices;
• Fully funding New York's Managed Care Consumer Assistance Program to ameliorate widespread consumer confusion and consumers' frequent inability to protect their rights and access benefits;
• Providing statutory penalties for violations to better address non-compliance by health care plans and providers with the Managed Care Consumer Bill of Rights, which provides managed care consumers with rights to certain coverage information, appeal and grievance processes and other protections.

Consumers who want to file a complaint about their health coverage or who are looking for assistance with regard to their health care plans or in obtaining health care coverage are encouraged to contact the Attorney General's helpline at (800) 771-7755, option 3.

To obtain a copy of the Health Care Bureau's 2003 Health Care Helpline Report, individuals are directed to visit the Attorney General's website at www.oag.state.ny.us.