HARTFORD, Connecticut -鈥� At 68, Maureen Smith has short, blonde hair, fashionable dark-framed glasses, and a soft, measured way of speaking that is the aural equivalent of comfort food.
The last is a particularly valuable trait because Smith frequently finds herself on the opposite end of the telephone with someone at the edge of desperation, if not a good deal beyond it. It might be a mother distraught after her teenage son has been rushed to an emergency room following a suicide attempt and her insurance carrier balks at paying for his hospital admission. It might be an elderly man enraged over a $75,000 hospital bill for a hip procedure that his insurer says it will not cover because it regards the operation as 鈥渆xperimental.鈥� Or it might be a young woman in tears because her insurance company will not pay $8,000 for a 鈥渟afety bed鈥� for her five-year old son whose cerebral palsy causes him to thrash about at night, keeping his parents sleepless and watchful out of fear that he will hurt himself.
Smith, director of consumer relations at the Connecticut Office of the Healthcare Advocate, put her shoulder into all three of these cases. She convinced the insurer not only to pay for the suicidal boy鈥檚 hospital admission for four days but also three weeks in an acute treatment center as well. The gentleman with the hip condition didn鈥檛 have to pay the $75,000. After examining medical literature, Smith was able to prove to the insurer that the procedure the man underwent was, in fact, the standard of care for his ailment.
And Smith managed to calm the mother of the child with cerebral palsy. The insurance representative who claimed the carrier didn鈥檛 pay for 鈥渄urable medical equipment鈥� didn鈥檛 know what he was talking about, Smith reassured the woman. 鈥淭hat denial,鈥� Smith said, 鈥渉ad absolutely no foundation whatsoever.鈥�
Federal Grants
Smith is the only employee at the Connecticut Healthcare Advocate鈥檚 office who has served since operations began in 2001. That makes her a pioneer in the field. Connecticut was one of the first states to establish such an agency, a response to the numerous complaints lawmakers were receiving at that time from constituents about their managed care plans. It has since assisted thousands of consumers in enrolling in health insurance plans and in settling health insurance disputes.
Congress liked what Connecticut was doing, enough to encourage other states to follow suit. A provision of the Affordable Care Act offers grant money for states to either strengthen existing healthcare advocacy programs or to begin them.
Washington has so far distributed around $45 million in Consumer Assistance Program grants to 36 states. Today, at least 22 states have created offices to provide consumer assistance to citizens on health insurance matters. Some of them, like Connecticut鈥檚, are an arm of state government. Others operate as non-profits.
One of the typical functions of these programs is helping consumers navigate the marketplace of health insurance, whose unfamiliar language, fine print and riders confuse even sophisticated buyers. The programs help buyers through the arcana to find the insurance plans that best fit their needs and those of their families.
In Connecticut, the Healthcare Advocate also assembles data on the performance of health insurance carriers and proposes legislation to make consumer-friendly improvements in health insurance matters.
Firepower
But it is the role of advocate that most endears consumer assistance programs to their clients, many of whom have waged lonely and unsuccessful fights over medical bills before discovering a knowledgeable and persistent ally.
鈥淚t鈥檚 a very onerous process to appeal an insurance company denial,鈥� says Victoria Veltri, the head of Connecticut鈥檚 Office of the Healthcare Advocate since 2011. 鈥淢ost people aren鈥檛 aware of how complicated the process is and what it takes to do it right.鈥�
The Health Care Advocate seems to be popular with almost everyone in Connecticut except the insurance industry, which pays for the program through mandatory fees charged to it by the state.聽While the industry doesn鈥檛 oppose states assisting consumers shopping for health insurance plans, once someone has enrolled, the industry prefers that policy holders deal directly with the carrier rather than a third party. 鈥淧lans have a long track record of providing assistance and helping facilitate appeals,鈥� says Robert Zirkelbach, a spokesman for the American Health Insurance Plans.
The problem, of course, is that when denials occur, consumers very quickly feel like adversaries rather than policyholders.
Veltri鈥檚 office represents clients from the moment of an initial denial to the end of the appeals process. Among those on the 15-person staff are lawyers, like Veltri, and nurses, like Smith. It鈥檚 a good deal more firepower than most consumers can bring to bear themselves.
鈥淭hey were constantly in contact with my insurance company, my surgeon and the hospital and me,鈥� says Joyce Back, a retired teacher from Groton and recent client of the Connecticut Healthcare Advocate. 鈥淎ny organization when it constantly gets dinged and they know they were wrong they鈥檒l pay more attention to a government advocate than to a private citizen.鈥�
Although Medicare paid 80 percent of the cost of Back鈥檚 breast reduction surgery, her supplemental insurance carrier had refused to pay the remaining 20 percent. It said cosmetic surgeries weren鈥檛 covered. But Valerie Wyzykowski, a Connecticut Healthcare Advocate case manager, realized that Back鈥檚 surgeon hadn鈥檛 made it plain that there was nothing cosmetic about the procedure; the surgery was necessary to relieve her chronic back pain. She counseled the surgeon in writing a more detailed explanation. The result: Back was relieved not only of her back pain but a $945 dunning notice.
Back found her way to the Advocate鈥檚 office thanks to a notice included in her denial letter from her insurance company. Connecticut law requires insurance carriers to provide information about Healthcare Advocacy when they issue denials to beneficiaries.
Saving $6 Million聽A Year
In 2011, Veltri鈥檚 office received 5,511 complaints on health insurance matters. The Advocate鈥檚 work that year resulted in $11 million in insurance pay-outs, an unusually high figure that resulted from a few large settlements. In a more typical year, the office recoups around $6 million. The office鈥檚 overall budget is about $1.5 million a year.
Some health policy organizations prefer healthcare assistance programs that operate as part of state government and others prefer the non-profit model, as it exists in New York and Massachusetts. Kate Bicego is the consumer assistance program manager for Massachusetts鈥檚 non-profit, Health Care For All, which has received federal consumer assistance money. She says her organization鈥檚 grassroots history has been indispensable in reaching underserved populations which might not otherwise contact a healthcare advocate鈥檚 office. She also says that being an independent organization gives her office credibility that a government agency wouldn鈥檛 have.
Veltri rejects that notion. She insists that her office does have independence; it is not part of the Connecticut Insurance Department, which regulates the industry. Veltri also points out that she has freedom to oppose other state agencies on policy matters. For example, in October, she publicly opposed the state鈥檚 proposal to alter Medicaid eligibility, saying that it would deprive 13,000 poor people in Connecticut of benefits.
鈥淚 don鈥檛 have any problem with non-profits doing this work, but being inside state government adds value to what we do, including access to data and access to other state agencies. And, from the consumers鈥� point of view, there鈥檚 nothing like the feeling of having a state agency being behind you.鈥�
As if to ram that point home, in the office down the hall, Demian Fontanella, the Healthcare Advocate鈥檚 general counsel, was on the phone with a 40-year old waitress from Hartford named Janice Chamberlain who needs surgery for endometrial cancer but has run through her insurance benefits. Fontanella was trying to get the hospital to take her on as a charitable case.
Although he had not yet received a definitive answer, he wanted to end his conversation with Chamberlain on a hopeful note. 鈥淚 will fight for this until I鈥檓 absolutely sure there鈥檚 nothing left to fight for,鈥� he told her. 鈥淚 live for this.鈥�