D.C. BAR PRO BONO PROGRAM HEALTH CARE ACCESS PROJECT Proposal I. OVERVIEW
Medical treatment, including hospitalization, is a significant contributing factor to personal debt. Medical debt is often described as “involuntary debt,” because an individual usually has little or no control over the circumstances leading to the debt. Nevertheless, medical debt can be just as devastating to an individual’s credit as any other form of indebtedness and poses obstacles to obtaining credit, housing, and employment. For individuals who work, wage garnishments used to enforce judgments in medical debt cases can turn a living wage into a poverty wage, jeopardizing the ability to pay for rent, utilities, food, and other essential items. In some cases, non-emergency medical services may be denied to individuals who owe unsatisfied medical debt or who are unable to pay in advance of receiving treatment. Although bankruptcy provides one avenue of relief for some individuals, it is often not an appropriate way to deal with medical debt. In many instances, non-bankruptcy remedies may be more effective to help an individual satisfy the debt and preserve his or her income and credit. For example, in many cases, medical bills can be paid by the individual’s insurance (whether private insurance or publicly funded programs such as Medicaid, Medicare, or D.C. Health Alliance), but are not because the insurer denied the claim in error or because the health care provider made a mistake in submitting the claim. Even when payment is made by the insurer, some health care providers engage in “balance billing” of Medicaid and Medicare recipients, illegally charging consumers for the difference between the reimbursement the provider has contracted to accept from the government insurer and the normal billing price for the medical service provided. In other cases, individuals may be eligible for free care by health care providers that are obligated to provide medical services to low-income individuals without insurance, but the health care provider has failed to inform patients of the availability of free care, as required by law, or the necessary request has not been made. Finally, individuals simply may not owe the amount billed, due to billing errors by the health care provider, and just need an advocate to help them resolve the disputed amount. Addressing these issues can reduce the financial burden on consumers and allow them to regain access to non-emergency care from providers. Consumers face other barriers to accessing medical care. Many insurers require pre-approval for certain kinds of care. If pre-approval is refused, low-income patients may have no choice but to forego treatment. Just as resolving billing errors can be challenging for many consumers, so can the pre-approval process, especially for those suffering from major health issues. In many cases, an advocate can assist a patient by working with the health care provider and insurer to obtain the necessary approval for care or by appealing the denial and ensuring that covered services are provided.
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II.
HEALTH CARE ACCESS PILOT PROJECT
Attempting to deal with the medical debt, and avoiding the long-term consequences of bankruptcy, better serve the goals of preserving income, credit, and access to medical care for low-income individuals. Like many consumers, however, those facing medical debt may not realize that there are options for resolving debt other than simply paying the creditor or possibly filing bankruptcy. For that reason, many individuals with medical debt may need an advocate who can identify the individual’s legal rights under the circumstances and effectively navigate the quagmire of hospital billing departments, insurance claims procedures, public benefits programs, and judicial debt collection proceedings. Even in the absence of other options for dealing with debt, an advocate can ensure that a fair payment plan is reached with the creditor. In cases in which a consumer cannot obtain pre-approval for care, an advocate can help the consumer and health care provider obtain pre-approval or appeal the denial. Therefore, the Pro Bono Program proposes to launch a Health Care Access Pilot Project. Individuals with medical debt that is jeopardizing their ability to meet their basic needs and who meet the Pro Bono Program’s guidelines for income and merit will be matched with volunteer attorneys who will work to advocate on behalf of the patients/consumers and resolve their debt. Likewise, individuals who are denied care because they cannot obtain pre-approval by their insurer will be matched with volunteer attorneys who will advocate to obtain the necessary approval. III. PROPOSED STRUCTURE AND SUPPORT A. Referrals
It is anticipated that most referrals will come from the Pro Bono Program’s Advice & Referral Clinics; the Small Claims/Consumer Law Resource Center; and from legal, medical/health care, and social services providers. Referring organizations will pre-screen individuals for income eligibility and, to the best of their ability, merit. A Referral Form containing the relevant information will be transmitted to the Program Coordinator. Upon receipt of the Referral Form, the Program Coordinator will contact the prospective client, obtain any other necessary information and inform the prospective client that he or she will be promptly advised of the Pro Bono Program’s decision of whether to schedule him or her for an appointment with a volunteer attorney. B. Services
The Health Care Access Pilot Project can function as an extension of the existing Bankruptcy Clinic, Law Firm Clinic, or as a stand-alone project. Eligible individuals will be placed with volunteer attorneys for advocacy/representation. The advocacy/ representation will employ both litigation and non-litigation strategies to resolve the debt or
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obtain pre-approval for treatment, including (i) representation in cases pending in D.C. Superior Court; (ii) working to obtain benefits to which the client is and/or was entitled under an insurance or public benefits program; (iii) working to reduce the debt due to unsubstantiated charges; (iv) negotiating a payment plan; (v) negotiating to obtain preapproval for treatment; and/or (vi) utilizing insurance company appeal procedures when pre-approval is denied. C. Volunteers
Volunteer attorneys will be drawn either from the Law Firm Clinic or from a pool of volunteers like those who volunteer for the Bankruptcy Clinic. In addition to large law firm attorneys, this project presents opportunities to involve small firm, solo, and government attorneys in pro bono cases. D. Support and Tracking
Inexperienced attorneys will be mentored by Program staff and experienced practitioners. A practice manual is being developed by the law firm of Skadden Arps and reviewed by experienced consumer and health care practitioners. All inexperienced attorneys will attend a training session or view a video of the training that provides substantive training. Each client’s case and the outcome of the representation will be tracked through periodic monitoring by Program staff within the first few weeks after the case is placed with a volunteer, at specific intervals during the course of representation and with reporting by volunteer attorneys at the termination of the representation. E. Timeline
It is anticipated that a pilot project could be in place by March 2009. This will allow sufficient time to develop a practice manual, recruit volunteer attorneys and mentors, and hold a training session. F. Evaluation
The Pro Bono Program will review the success of the Health Care Access Pilot Project about 6 months after it is launched to evaluate outcomes and impact, including number of clients served.
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