HMOs fined for tactics to enroll poor State cites two firms for cases involving Medicaid recipients

Appeals planned

Companies deny improprieties in marketing practices

June 24, 1996|By Diana K. Sugg | Diana K. Sugg,SUN STAFF

Despite warnings and other efforts to curb abuses by HMOs trying to enroll the poor, state health officials recently fined Prudential Health Care and Total Health Care $5,000 apiece for improperly signing up people in their HMOs.

Both companies are appealing the fines.

The cases are the latest in a string of marketing problems linked with HMOs that want to provide health care to Maryland's Medicaid recipients. The state pays each HMO a fee based on the number of people enrolled each month.

The fines were levied last month. They were begun last year by state officials as a way to curb such tactics as forgery and bribery that some of the health plans' employees were using in the aggressive competition to recruit Medicaid patients.

According to documents obtained by The Sun under the Freedom of Information Act, in one case, a mother says she signed her daughter up for Prudential Health Care, only after a marketer told her Prudential was taking over the Medicaid program. The mother said she was afraid her daughter wouldn't be able to get health services unless she enrolled her in Prudential.

In reality, Medicaid recipients still have a choice of signing up for one of several HMOs, or a less restrictive system called "MAC," or Maryland Access to Care.

In a letter to state officials, Prudential's president, Elizabeth J. Misek, said that the person marketing the HMO was "simply and truthfully" attempting to explain the coming switch, in which 210,000 Maryland Medicaid recipients will be required to enroll in HMOs between January and June 1997.

Misek said there was no intentional misrepresentation. Prudential officials also said they have "counseled" the marketer involved and all other marketing employees.

The plan, which begins on Jan. 1, is designed to hold down the state's Medicaid costs and better coordinate care for recipients.

State health officials sent out a letter in late March, warning HMOs not to deliberately confuse recipients in the months leading up to the change.

In the second case, Total Health Care was fined for conducting an enrollment presentation in an inappropriate environment. An elderly man, who can't read and has cognitive deficits from a 1993 stroke, was enrolled in the lobby of his senior citizen high-rise, according to state officials.

They said the man had the impression he could continue to use his current providers, as well as go to Total Health Care.

But Total Health Care officials say the lobby environment was quiet and peaceful. They said the person marketing the HMO had finished talking with another resident and was in the elevator when she met the elderly man, who questioned her about the program. She finished the conversation in the lobby, and he enrolled. The HMO's official also disputes the man's condition.

"The man had enough cognitive abilities to recite a litany of activities that led up to him signing this contract," said Vanessa Carroll, vice president for marketing and development at Total Health Care. "We really try to do everything right."

She said the HMO's marketer was not disciplined because no such action was warranted.

Maryland already is paying HMOs about $288 million to care for roughly a quarter of the 467,000 residents on Medicaid.

Last year, after an investigation by the attorney general's office, more than two dozen people were found guilty of crimes ranging from bribery and forgery to Medicaid fraud in the marketing of HMOs to potential patients. Similar abuses have occurred around the country.

Because of the problems, state health officials have decided to prohibit HMOs from enrolling patients, a provision that takes effect Oct. 1. Some HMO representatives said they welcome that change.

"How many $5,000 fines can you take?" asked Carroll of Total Health Care. "The big issue is quality health care.

"We're not a marketing organization. We're a health-care provider. We want to eliminate that as an issue."

Pub Date: 6/24/96

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