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.

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Bernice Steinhardt
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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.

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