ILLINOIS ATTORNEY GENERAL’S OFFICE HEALTH CARE BUREAU.

Slides:



Advertisements
Similar presentations
Whats Going On At The Workers Compensation Division.
Advertisements

BIE SPECIAL EDUCATION ACADEMY PRESENTERS: JUDY WILEY AND NARCY KAWON I ntroduction to Procedural Safeguards Bureau of Indian Education.
Chapter 27 Your Credit and the Law pp Learning Objectives 1.Explain 1.Explain how government protects credit rights. 2. Name 2. Name federal.
Health Care Self-Advocacy for People with Disabilities Disability and Employment Rights Advocacy Spring 2008.
OVERVIEW OF THE FLORIDA BAR DISCIPLINE SYSTEM November 30, 2006.
1 Getting Basic Health Care Services & Medically Necessary Treatment from your Health Plan Presenters: Lyn Gage, R.N. and Susan Burger Family Voices of.
Claims Follow-up Claim Status Balance Billing Appeals.
1 HIPAA Education CCAC Professional Development Training September 2006 CCAC Professional Development Training September 2006.
WHAT IS HIPAA? The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides certain protections for any of your health information.
Corporate Compliance Instructor Notes:
Deceptive/False/Unfair Advertising Emma Kazaryan Street Law.
Enforcing Forum Selection Provisions Legal Considerations Brian S. Inamine, Esq. LeClairRyan - Los Angeles Office.
Consumer Protection in the CNMI Gus Harb Assistant Attorney General.
Copyright 2007 Thomson South-Western Chapter 9 Credit Problems and Laws.
PRIVACY BREACHES A “breach of the security of the system”: –Is the “unauthorized acquisition of computerized data that compromises the security, confidentiality,
RMG:Red Flags Rule 1 Regal Medical Group Red Flags Rule Identify Theft Training.
CONSUMER CREDIT LEGISLATION Carl Johnson Financial Literacy Jenks High School.
Chapter 9-Section 3 Consumer Protection Laws. Consumer Credit  Credit Denial  If denied credit there could be something in your credit file preventing.
Paul DuBois – Compliance Analyst.  Answers consumer inquiries about insurance and their legal rights  Investigates complaints filed against insurance.
SEMINAR NAIC/ASSAL/SVS REGULATION & SUPERVISION OF MARKET CONDUCT © 2014 National Association of Insurance Commissioners Complaint Handling.
Employment Screening: CORI and Private Background Checks Presented by the Massachusetts Law Reform Institute 99 Chauncy St., Suite 500, Boston, MA
HIPAA COMPLIANCE IN YOUR PRACTICE MARIBEL VALENTIN, ESQUIRE.
Implementing and Enforcing the HIPAA Privacy Rule.
Lesson 9-3 Consumer Protection Laws LEARNING GOALS -LIST AND EXPLAIN CONSUMER PROTECTION LAWS THAT ARE RELATED TO CREDIT -DISCUSS THE PROCESSES OF USING.
Presented by Steven Russo, Chief of Investigations September 19, 2012 The State Auditor’s Whistleblower Program.
The Informal Complaint Process  The informal complaint process is the process most typically used by residential and small commercial customers.  It.
WHO’S IN YOUR “WALLET” WHO’S IN YOUR “WALLET” YOU BETTER “RECOGNIZE” YOU BETTER “RECOGNIZE” STEPPING $200 $200 $300 $400 $500 $400 $300 $200 $500 $400.
Copyright© 2011 WeComply, Inc. All rights reserved. 9/6/2015 Whistleblowing.
IDEA 2004 Procedural Safeguards: Legal Rights and Options Mississippi Association of School Superintendent Spring, Mississippi Department of Education.
COMPLIANCE PROGRAM. Agenda  Initial Scenarios  Review of General Compliance Information  Review UCP’s Compliance Program  Questions and Discussion.
An Outline of Florida PIP Reform HB 119 Amended and Passed by the Legislature.
Compliance and Enforcement of the Privacy Rule. HHS/OCR February/March Compliance Date  April 14, 2003 – Compliance for all but small health plans.
Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative.
© 2009 Foley Hoag LLP. All Rights Reserved.Presentation Title Final Massachusetts Pharmaceutical and Medical Device Regulations Penalties and Enforcement.
WHEN THE DEPARTMENT OF JUSTICE KNOCKS DOJ Enforcement Trends: What to Expect and How to Respond Jacqueline Arango Shareholder Akerman Senterfitt.
 Texas Self-Insurance Association 2009 Educational Conference Compliance Monitoring in the Workers’ Compensation System Teresa Carney Texas.
Fraud and Abuse in Dentistry. Definition Fraud is the intentional perversion of truth in order to induce another to part with something of value, or surrender.
Because your patients come first. Regulatory and Practice Management Services Daniel L. Johnson, CPC, CPC-H.
Building a Privacy Foundation. Setting the Standard for Privacy Health Insurance Portability and Accountability Act (HIPAA) Patient Bill of Rights Federal.
Prevailing Wage Enforcement Fair Labor Division Office of Attorney General Martha Coakley Jocelyn B. Jones, Deputy Chief & Assistant Attorney General Prevailing.
Chapter 45 Consumer Law McGraw-Hill/Irwin Copyright © 2012 by The McGraw-Hill Companies, Inc. All rights reserved.
Chapter 16.1 Civil Cases. Types of Civil Lawsuits In civil cases the plaintiff – the party bringing the lawsuit – claims to have suffered a loss and usually.
THE REVIEW PROCESS. 2 OVERVIEW Taxpayers’ Bill of Rights Request Departmental Review Review Process Documentation Conference Final Determination Other.
Learn how you can provide effective assistance to identity theft victims in your community.
C HAPTER 34 Code Blue Health Sciences Edition 4. Confidentiality of sensitive information is an important issue in healthcare. Breaches of confidentiality.
Mediation with the Information Commissioner’s Office Cory Martinson Appeals and Policy Analyst 25 November 2009.
Illinois Department of Insurance By Jim Norris, Outreach Officer Overview of the IL Dept. of Insurance presented to: The Arc of Illinois Health Seminar.
© 2013 BALANCE / REV0513 Identity Theft Identity theft can be one of the most shocking and upsetting events to ever happen to you. Fortunately, there are.
Understanding Business and Personal Law Consumer Protection Section 15.1 Consumer Protection and Product Liability Years ago, caveat emptor, which means.
Lesson 29.1 Laws to Protect Consumers
HIPAA Privacy Rule Implementation Status Report Richard M. Campanelli, J.D. Director, Office for Civil Rights Before the The Tenth National HIPAA Summit.
Medical Documentation
HIPAA Overview Why do we need a federal rule on privacy? Privacy is a fundamental right Privacy can be defined as the ability of the individual to determine.
© South-Western Educational Publishing Chapter 30 Dispute Resolution  The Legal System  Other Ways to Seek Redress.
Standard 3 Objective 4 Describe the rights and responsibilities of buyers and sellers under consumer protection laws.
Disclaimer This presentation is intended only for use by Tulane University faculty, staff, and students. No copy or use of this presentation should occur.
Navigating the CFPB's Exam and Enforcement Process October 22, 2016
DOL Employee Benefit Plan Audits & How to Prepare
THE FEDERAL TRADE COMMISSION UNDER THE TRUMP ADMINISTRATION: PAST, PRESENT, AND FUTURE February 15, 2017.
Federal Agencies and Laws for Consumer Rights
RISK MANAGEMENT IN THE TREATMENT OF OPIOID DEPENDENCE
ALL ABOUT THE FTC By: Brandon Baldwin.
Pennsylvania Insurance Department Complaint Handling
By: Taylor, Grace, Tiffany, and Donelda
COMPLIANCE PROGRAM.
Lesson 6 Topic 2 Claims Problems and Appeals
Compliance and Enforcement of the Privacy Rule
Consumer Protection Laws
Managed Care: Dealing with Problems
Presentation transcript:

ILLINOIS ATTORNEY GENERAL’S OFFICE HEALTH CARE BUREAU

Outline for Presentation What is the Health Care Bureau What types of complaints are appropriate Staff/ what do they do How do I file a complaint/what happens next Advocacy / Mediation Typical investigations How cases are resolved What laws enforced Lawsuits filed/ possible remedies available 2

What is the Health Care Bureau? Consumer Protection Division Health Care Assistance Education Law enforcement Attorneys/ Mediators/ Medical Director/Intake 3

Health Care Bureau The Health Care Bureau currently operates a toll- free hotline as a way for consumers to ask questions, file complaints or request assistance in resolving specific problems The hotline number is (877) ; (tty ). Each year the bureau handles thousands of complaints & recovers millions of dollars on behalf of consumers in out-of-pocket health care costs. 4

Health Care Bureau Staff Help Consumers: Challenge erroneous health plan decisions Correct health plan or provider errors Understand their health plans Recover out-of-pocket expenses wrongfully charged Understand their health care rights Understand health & consumer protection laws 5

Common Complaints Billing disputes Denial of coverage Denial of treatment as not medically necessary False or misleading health care advertising Unfair insurance practices Unfair debt collection practices Partial payments on claims when the consumer is entitled to more Difficulty navigating the appeals process when a claim is denied 6

Other Common Complaints Difficulty in obtaining referral to specialist In vs. Out of Network payment coverage DME cases Difficulty obtaining medical records from provider Permanent Hair removal/Hair Growth Medical Spas 7

Complaints Continued The majority of consumers complain about problems with their private insurance, others complain about healthcare providers We provide health care assistance to consumers having problems accessing the benefits of their governmental health plans and health products 8

Health Care Provider Complaints Quality of Care Advertising Billing Unlicensed 9

Health Care Bureau Staff Attorneys Mediators Medical Director Intake 10

How to File a Complaint/What Happens Next? Regular mail Fax OAG Website Telephone/ TTY 11

Intake Calls are received through our toll-free hotline Intake personnel get the basic facts and determine whether the dispute is appropriate for the bureau to review or handle If the dispute is appropriate, case is opened & assigned to a mediator 12

Advocacy/Mediation Mediator collects details from consumer Sends consumer a release of information request Mediator calls insurance company or health care provider Mediator may request consumers’ medical records & information from health care provider or insurer. 13

Advocacy Continued Mediators solicit and write letters of support Medical Director solicits and writes letters of support Attorneys provide legal support and research on mediation, as needed Medical Director provides medical support and research, as needed 14

Advocacy Continued Most cases settle through mediation A substantial percentage of cases have been resolved to the consumers’ satisfaction 15

Typical Mediation Matters Medical necessity denials based on experimental or investigational Outdated drug formularies and provider networks Claims processing and payment problems Denial due to health plan error Barriers to service 16

Mediation Results Cochlear Implant Bariatric Cases Breast Reduction Tumor Removal Aneurysm Victim 17

Investigations If case can’t be resolved through mediation, case may be assigned to an attorney for investigation Most investigations are initiated by a Civil Investigative Demand – subpoena If failure to respond then subpoena enforcement action If the investigation concludes that the activity could be a violation of the Illinois Consumer Fraud Act, the Attorney General may file a lawsuit 18

Typical Investigations False or misleading health care advertising Unfair insurance practices Unlicensed providers Unsubstantiated Health Claims 19

Consumer Fraud Act Protects consumers and businesses from unfair or deceptive acts and practices that occur in trade or commerce Including matters of fraud and unlawful practices Attorney General is charged with enforcing the Act Remedies: injunction, civil penalty, restitution & disgorgement of profits 20

Health Care Bureau attorneys conduct investigations and file lawsuits to enforce consumer protection laws. These lawsuits include: Health plans Insurance & Health providers Individuals and entities – that engage in fraudulent, misleading, deceptive, unfair or illegal practices in the health care market 21

How Cases are Resolved Letter Assurance of Voluntary Compliance Chancery lawsuit 22

What Laws Enforced Illinois Consumer Fraud Act (815 ILCS 505/1) Illinois Medical Practice Act (225 ILCS 60) Illinois Dental Practice Act (225 ILCS 25) Illinois Fair Patient Billing Act (210 ILCS 88) Illinois Uninsured Patient Discount Act (210 ILCS 89) 23

OFFICE OF THE ILLINOIS ATTORNEY GENERAL LISA MADIGAN Health Care Bureau 100 West Randolph Street, 12 th Floor Chicago, Illinois Fax: Health Care Bureau TTY: