HMO Complaints and Appeals:

Plans' Systems Have Most Key Elements, but Consumer Concerns Remain

T-HEHS-98-173: Published: May 19, 1998. Publicly Released: May 19, 1998.

Additional Materials:

Contact:

Bernice Steinhardt
(202) 512-3000
contact@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

GAO discussed its recent report on health maintenance organization (HMO) complaint and appeal procedures, focusing on: (1) the elements that are considered important to a system for processing HMO members' complaints and appeals; (2) the extent to which HMOs' complaint and appeal systems for members contain these elements; (3) the concerns that consumers have regarding HMO complaint and appeals systems; (4) the information that is available on the number and types of complaints and appeals HMOs receive from their members; and (5) how, if at all, HMOs use their complaint and appeal data.

GAO noted that: (1) the HMOs in its study have most elements identified as important by regulatory, consumer, and industry groups; (2) however, GAO found: (a) considerable variation in how the HMOs specify certain policies; (b) poor understanding of HMO systems by members; and (c) a lack of consistency in the way the HMOs define, collect, and maintain data in complaints and appeals; (3) GAO examined HMOs' time periods, decisionmaking processes, and communication with members regarding their complaints and appeal systems; (4) consistently, the plans have 9 of the 11 key elements in their policies and procedures; (5) even where GAO found a policy or procedure to be common across HMOs, plans exhibit considerable variation in the specifics of certain policies; (6) most HMOs told GAO that they include medical professionals among the appeal decisionmakers; some plans use physicians not employed by the plan to review appeals; (7) although the majority of HMOs' complaint and appeal systems include most of the important elements, consumer advocates expressed concern that such systems are not fully meeting the needs of enrollees; (8) advocates specifically noted the lack of an independent, external review of plan decisions on appeals and noted members' difficulty in understanding how to use complaint and appeal systems; (9) the most common complaints were about medical or administrative services, quality of care, and claims issues; the most common appeals were appeals of benefits issues, denial of payment for emergency room visits, and referral issues; and (10) all HMOs in GAO's study told GAO that they analyze complaint and appeal data to identify systemic problems and opportunities for improvement.

Sep 29, 2016

Sep 28, 2016

Sep 15, 2016

Sep 14, 2016

Sep 12, 2016

Sep 9, 2016

Sep 6, 2016

Looking for more? Browse all our products here