Medicare Part D:

Complaint Rates Are Declining, but Operational and Oversight Challenges Remain

GAO-08-719: Published: Jun 27, 2008. Publicly Released: Jul 28, 2008.

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Medicare Part D coverage is provided through plan sponsors that contract with the Centers for Medicare & Medicaid Services (CMS). As of April 2008, about 26 million beneficiaries were enrolled in Part D. When beneficiaries encounter problems with Part D, they can either file a complaint with CMS or a grievance with their plan sponsors. CMS centrally tracks complaints data and plan sponsors must report summary data on grievances for each of their contracts. GAO provided information on (1) complaints and what they indicate about beneficiaries' experiences with Part D, (2) whether grievances data provide additional insight about beneficiaries' experiences, and (3) CMS's oversight of the complaints and grievances processes. To conduct its work, GAO reviewed CMS's complaints and grievances data and interviewed the plan sponsors of eight, judgmentally selected contracts, which accounted for 40 percent of 2006 enrollment.

While the number of complaints filed with CMS and the time needed to resolve them has diminished as the Part D program has matured, complaints data indicate that ongoing challenges pose problems for some beneficiaries. From May 1, 2006, through October 31, 2007, about 630,000 complaints were filed; most complaints were related to problems in processing beneficiaries' enrollment and disenrollment requests. The monthly complaint rate declined by 74 percent over the period, and the average time needed to resolve complaints decreased from a peak of 33 days to 9 days. However, trends in the complaints data also indicate ongoing implementation issues, such as information-processing issues related to beneficiaries' requests for enrollment changes and automatic premium withholds from Social Security payments. In addition, CMS and plan sponsors did not resolve a significant proportion of complaints related to beneficiaries at risk of depleting their medications in accordance with applicable time frames. Due to limitations and anomalies, the grievances data that plan sponsors reported for their contracts did not provide sufficient insight into beneficiaries' experiences with Part D. Specifically, these data did not include information about whether beneficiaries who filed grievances were at risk of depleting their medications or whether plan sponsors were resolving grievances in a timely manner. In addition, GAO identified a number of anomalies in the grievances data, raising questions about whether plan sponsors were reporting these data consistently and accurately. For example, reported grievances were concentrated in a small number of plan sponsors' contracts and at a rate that was significantly disproportionate to their respective enrollment levels; varied considerably among contracts with similar levels of enrollment; and increased from 2006 to 2007, in contrast to patterns in complaints data. CMS's oversight efforts thus far have focused almost exclusively on resolving complaints with little attention devoted to plan sponsors' grievances processes. CMS routinely monitors the status of complaints and has taken actions against plan sponsors who failed to comply with requirements for the complaints process. In contrast, CMS oversight of plan sponsor grievances processes has been more limited. CMS provided plan sponsors with general guidance for classifying grievances and periodically reviewed these data. However, several plan sponsors indicated that the guidance was insufficient, increasing the likelihood that plan sponsors report erroneous and inconsistent information to CMS and that they rely on the wrong processes to address beneficiaries' concerns. Further, CMS could not explain many of the anomalies in the grievances data that GAO identified.

Recommendation for Executive Action

  1. Status: Closed - Implemented

    Comments: CMS agreed with the recommendation and indicated they have been working to improve the consistency, reliability, and usefulness of grievance data reported by Medicare Part D plan sponsors. Over the past year, CMS has taken a number of actions to address our recommendation. First, to help sponsors determine whether beneficiaries' problems are grievances rather than coverage determinations or other issues, and ensure sponsors report consistent information, CMS has provided information on both the 2010 Part D reporting requirements and technical specifications to help clarify for sponsors which items are grievances. Specifically, in the 2010 reporting requirements they reminded sponsors about the differences between such issues, and in the technical specifications document provided a link to the regulations implementing the Part D program and drug benefit manual which provides more detailed instructions on what is a grievance and how it differs from other issues such as coverage determinations. Second, in the 2010 reporting requirements, CMS is mandating that plan sponsors provide information on whether they notified beneficiaries, in a timely manner, as to the status and resolution of the grievance. This will give CMS an indication as to whether sponsors are closing grievances in a timely manner. Finally, CMS has hired a contractor to routinely monitor the sponsor-reported grievance data. The contractor will be reviewing the data for reliability purposes to identify obvious outliers such as the ones GAO identified, and will be conducting routine trend analyses of the grievance data. This will include calculating grievance rates, and identifying outliers based on those rates. Based on the contractor's analyses, CMS will be routinely sending out administration action letters notifying sponsors that they outliers with respect to their grievance rates. The contractor will also be looking for overall patterns across the reporting periods to identify more systemic issues across the program or specific plans.

    Recommendation: To improve oversight of the Medicare Part D grievances process, and provide added assurance that beneficiaries' grievances are being resolved, CMS should undertake efforts to improve the consistency, reliability, and usefulness of grievances data reported by plan sponsors for each of their contracts. Such efforts include enhancing its existing guidance for determining whether beneficiaries' problems are grievances, requiring plan sponsors to report information regarding the status and issue level of grievances, and conducting systematic oversight of these data.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services


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