Medicare Managed Care: Greater Oversight Needed to Protect Beneficiary
Rights (Letter Report, 04/12/99, GAO/HEHS-99-68).

Pursuant to a congressional request, GAO reviewed Medicare's managed
care beneficiary appeals process, focusing on: (1) the appeals process
available to beneficiaries when managed care plans deny care or payment
for services; (2) beneficiaries' use of the appeals process and the
extent to which they are informed of their appeal rights; and (3) the
Health Care Financing Administration's (HCFA) oversight of this process.

GAO noted that: (1) Medicare beneficiaries enrolled in managed care
plans have the right to appeal if their plans refuse to provide health
services or pay for services already obtained; (2) upon receipt of the
written denial notice, the beneficiary may appeal and the health plan
must reconsider its initial decision; (3) if the plan's reconsidered
decision is not fully favorable to the beneficiary, the case is
automatically sent to the Center for Health Dispute Resolution (CHDR) to
review the decision; (4) CHDR may overturn or uphold the plan's
decision; (5) a beneficiary is entitled to an expedited decision from
the plan, both on the initial request and on appeal, if the standard
time for making the decision could endanger his or her health or life;
(6) a beneficiary who is dissatisfied with CHDR's decision may appeal
further to an administrative law judge and then to a U.S. District Court
provided certain requirements are met; (7) health maintenance
organizations (HMO) reported an average of approximately 9 appeals per
1,000 Medicare members annually between January 1996 and May 1998; (8)
HMOs reversed their original denial in about 75 percent of appeal cases;
(9) the number of appeals may understate beneficiaries' dissatisfaction
with the initial decisions by HMOs for two reasons: (a) some
beneficiaries may disenroll and switch to another plan or
fee-for-service Medicare instead of appealing; and (b) some
beneficiaries may not appeal because they are unfamiliar with their
appeal rights or the appeals process; (10) GAO found that beneficiaries
frequently received incomplete notices that failed to explain their
appeal rights, and some beneficiaries did not receive any notices; (11)
notices often do not state a specific reason for the denial; as a
result, beneficiaries may be uncertain as to whether they are entitled
to the requested services and thus discouraged from appealing; (12) GAO
also found that beneficiaries may receive little advance notice when
plans decide to discontinue paying for services, which places these
beneficiaries at financial risk should they decide to continue treatment
during their appeal; (13) beneficiaries who lose their appeals are
responsible for the treatment costs incurred after the date specified in
the denial notice; (14) the agency does not determine whether
beneficiaries who were denied services but did not appeal were informed
of their appeal rights, nor does it monitor provider groups that
contract with health plans; and (15) HCFA has not used available
information to develop more effective plan oversight strategies.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-99-68
     TITLE:  Medicare Managed Care: Greater Oversight Needed to Protect
	     Beneficiary Rights
      DATE:  04/12/99
   SUBJECT:  Health care services
	     Health services administration
	     Health maintenance organizations
	     Beneficiaries
	     Managed health care
	     Medical expense claims
	     Health care programs
	     Dispute settlement
	     Claims settlement
	     Skilled nursing facilities
IDENTIFIER:  Medicare Program

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MEDICARE MANAGED CARE: Greater Oversight Needed to Protect
Beneficiary Rights GAO/HEHS-99-68 United States General Accounting
Office

GAO Report to the Special Committee on Aging, U. S. Senate, and
the Honorable

Jack Reed

April 1999 MEDICARE MANAGED CARE Greater Oversight Needed to
Protect Beneficiary Rights

GAO/HEHS-99-68

  GAO/HEHS-99-68

GAO United States General Accounting Office

Washington, D. C. 20548 Health, Education, and Human Services
Division

B-281220 April 12, 1999 The Honorable Charles E. Grassley Chairman
The Honorable John Breaux Ranking Minority Member Special
Committee on Aging United States Senate

The Honorable Jack Reed United States Senate

Since 1994, enrollment of Medicare beneficiaries in managed care
has tripled to 7 million comprising 18 percent of all Medicare
beneficiaries. Beneficiaries who enroll in managed care are
entitled to all Medicare- covered services. They also may benefit
from lower out- of- pocket costs, additional covered benefits, and
less paperwork than their counterparts in traditional fee- for-
service Medicare. Unlike fee- for- service providers, however,
managed care plans receive a fixed amount per month for each
enrolled beneficiary, regardless of the type and number of
services they provide. Consequently, plans have a financial
incentive to limit beneficiaries' use of health care services. To
safeguard access to appropriate covered services, Medicare allows
beneficiaries to appeal first to their managed care plans and then
externally whenever their health plans deny requested care or
refuse to pay for services. 1

Because the appeals process helps safeguard Medicare
beneficiaries' right to covered services from managed care plans,
you asked us to assess the adequacy of the process, including the
recently instituted expedited process. Specifically, you asked us
to focus on the appeals process at the plan level, providing
information on (1) the appeals process available to beneficiaries
when managed care plans deny care or payment for services, (2)
beneficiaries' use of the appeals process and the extent to which
they are informed of their appeal rights, and (3) the Health Care
Financing Administration's (HCFA) oversight of this process.

To conduct our review, we interviewed officials from HCFA; the
Center for Health Dispute Resolution (CHDR), HCFA's contractor
that reviews plans' appeal decisions; and selected managed care
plans. We also reviewed HCFA's 1997 managed care plan monitoring
reports and reports by the

1 Similarly, beneficiaries in fee- for- service Medicare who
disagree with a decision on the amount Medicare will pay on a
claim or whether services received are covered by Medicare may
appeal the decision.

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 1

B-281220

Office of Inspector General (OIG) in the Department of Health and
Human Services (HHS), analyzed the results of a questionnaire sent
to all health maintenance organizations (HMO) about their plan-
level appeals, reviewed a number of appeals forwarded to CHDR, and
collected statistical data from HCFA and CHDR on plan appeals. In
addition, we accompanied agency staff on two monitoring visits to
plans and visited four HMOs. We performed our work between June
1998 and April 1999 in accordance with generally accepted
government auditing standards. (See app. I for details on our
scope and methodology.)

Results in Brief Medicare beneficiaries enrolled in managed care
plans have the right to appeal if their plans refuse to provide
health services or pay for services

already obtained. For example, if a plan denies a beneficiary's
request for skilled nursing care or a referral to a specialist, it
must issue a written notice that explains the reason for the
denial and the beneficiary's appeal rights. Upon receipt of the
written denial notice, the beneficiary may appeal and the health
plan must reconsider its initial decision. If the plan's
reconsidered decision is not fully favorable to the beneficiary,
the case is automatically sent to CHDR to review the decision.
CHDR may overturn or uphold the plan's decision. A beneficiary is
entitled to an expedited decision from the plan, both on the
initial request and on appeal, if the standard time for making the
decision could endanger his or her health or life. A beneficiary
who is dissatisfied with CHDR's decision may appeal further to an
administrative law judge (ALJ) and then to a U. S. District Court,
provided certain requirements are met.

HMOs reported an average of approximately 9 appeals per 1,000
Medicare members annually between January 1996 and May 1998. HMOs
reversed their original denial in about 75 percent of appeal
cases. The number of appeals, however, may understate
beneficiaries' dissatisfaction with the initial decisions by HMOs
for two reasons. First, some beneficiaries may disenroll and
switch to another plan or fee- for- service Medicare instead of
appealing. Second, some beneficiaries may not appeal because they
are unfamiliar with their appeal rights or the appeals process. We
found that beneficiaries frequently received incomplete notices
that failed to explain their appeal rights; some beneficiaries did
not receive any notices. In addition, notices often do not state a
specific reason for the denial; as a result, beneficiaries may be
uncertain as to whether they are entitled to the requested
services and thus be discouraged from appealing. We also found
that beneficiaries may receive little advance notice when plans
decide to discontinue paying for services, such as skilled nursing
care,

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 2

B-281220

which places these beneficiaries at financial risk should they
decide to continue treatment during their appeal. In general,
beneficiaries who lose their appeals are responsible for the
treatment costs incurred after the date specified in the denial
notice.

HCFA's oversight of health plans' appeals process has several
shortcomings. The agency does not determine whether beneficiaries
who were denied services but did not appeal were informed of their
appeal rights. It also does not monitor provider groups that
contract with health plans. Many of these groups play a key role
in the appeals process by issuing denial notices and deciding
whether to expedite initial decisions. HCFA has not ensured
consistent implementation of the expedited appeals process because
it has not issued specific criteria for expedited cases. We found
that a group of health plans in one HCFA region had collaborated
to develop such criteria. The HCFA regional office subsequently
issued these criteria to plans in its region. Finally, HCFA has
not used available information to develop more effective plan
oversight strategies. The agency is planning to gather plan- level
appeals data (similar to the data we collected for this report),
but actual data collection may not begin for another year. In
commenting on a draft of this report, HCFA agreed that the agency
needs to improve its oversight of the appeals process. HCFA cited
several initiatives it is currently undertaking to better protect
beneficiaries' rights.

Background In 1998, about 7 million or 18 percent of Medicare's 39
million beneficiaries were enrolled in a managed care plan. About
90 percent of

Medicare managed care enrollees belong to one of 307 risk-
contract HMOs. 2 These plans are paid a predetermined monthly
amount for each Medicare enrollee, regardless of the amount of
Medicare covered services the enrollee uses. The plans are called
risk HMOs because they assume the financial risk of providing care
for the amount Medicare pays.

Risk HMOs must provide all services covered by fee- for- service
Medicare; in many instances, they provide additional services such
as outpatient prescription drugs and routine physical exams.
Generally, plans require enrollees to use only providers that
contract with the plan and to follow certain procedures to obtain
health care services. For example, most plans require enrollees to
obtain prior authorization for care either from their primary care
physician or directly from the plan. If enrollees do not follow
the procedures, plans may not pay for the services.

2 There are also cost- contract plans, where Medicare pays the
actual cost the entity incurs in furnishing covered services less
the estimated value of beneficiary cost- sharing, and health care
prepayment plans, which are similar to cost- contract plans except
that they provide only Medicare part B services.

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B-281220

HCFA Performs On- Site Monitoring of Plans Every 2 Years

HCFA performs biennial on- site performance reviews of each health
plan's operations, including the appeals process, to evaluate plan
compliance with HCFA regulations. HCFA staff review a sample of
appeal cases and evaluate whether the plan met Medicare process
and timeliness requirements. Results of the performance review are
reported in the monitoring report. The report documents whether a
plan met all legal and policy requirements and describes any
deficiencies and needed corrective actions.

Class Action Lawsuit Challenges Medicare HMOs Appeal Practice

In November 1993, a class action lawsuit filed against the
Secretary of HHS challenged a number of the policies and practices
of the Medicare managed care program. As a result of this lawsuit,
HCFA is currently under an injunction and order issued by the
federal district court that requires Medicare HMOs to give their
enrollees written notices that meet certain criteria. 3
Specifically, the order required, among other things, that
Medicare HMOs (1) issue denial notices within no more than 5
working days of the request for service or payment and at least 1
working day before the reduction or termination of treatment, (2)
clearly state the reason for the denial in the notice, (3)
expedite appeals when services are urgently needed (within 3
working days of the request), and (4) continue acute care services
until a final appeal decision is issued when the beneficiary
requests an expedited appeal. 4

Since the 1997 court order, HCFA has required each plan to
implement an expedited process for decisions on initial requests
for health services and appeals of denied health services.
Subsequently, the expedited process was mandated along with other
appeals procedures and beneficiary protections by the Balanced
Budget Act of 1997 (BBA) and further addressed in the Medicare+
Choice regulations published in June 1998. A beneficiary may now
request an expedited decision if he or she believes that serious
adverse health consequences could result from waiting for a
decision under the standard process.

3 Grijalva v. Shalala, 946 F. Supp. 747 (D. Ariz. 1996), Oct. 17,
1996; subsequent judgment implementing the order was issued Mar.
3, 1997. 4 HCFA appealed the decision of the lower court to the U.
S. Court of Appeals for the 9th Circuit, which on August 12, 1998,
upheld the lower court's decision. HCFA's second appeal was also
denied. On February 10, 1999, HCFA asked the U. S. Supreme Court
to review the case.

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 4

B-281220

Medicare Beneficiaries Can Appeal Plan Decisions

Medicare beneficiaries enrolled in managed care plans have a
multilevel appeals process available if plans refuse to pay for
requested services, refuse to provide requested services, or
discontinue or reduce services. 5 Beneficiaries generally appeal
to their plan first. 6 If the plan upholds the initial denial, the
appeal is forwarded to CHDR for external review and resolution. 7
However, a further appeal to an ALJ and the court is possible.
Under certain circumstances, a beneficiary or a health care
provider may request that a plan expedite its decision on the
initial request and any subsequent appeal.

Appeals Process Starts at Managed Care Plan but Is Subject to
External Review

The appeals process may begin when a Medicare member asks his or
her plan to provide a service, such as skilled nursing care or a
referral to a specialist, or pay for a service already obtained
and is turned down. 8 In such instances, Medicare requires plans
to issue a written notice that states the reason for the denial
and explains the beneficiary's appeal rights. A member has 60 days
from the date of the denial notice to ask the plan to reconsider
its initial decision. 9 The appeal request, which must be in
writing, can be addressed to the member's health plan or the
Social Security Administration, which will forward it to the
health plan. A member is not required to submit additional
information to support or clarify the request. However, health
plans must provide their members the opportunity to supply such
information.

The plan's reconsideration of its initial decision, the internal
portion of the appeals process, must conform to certain
requirements. Prior to July 27, 1998, 10 a plan had up to 60 days
to complete this process; now a plan must reconsider its initial
decision within 30 calendar days if the request is for

5 Health plans must also have a process for handling beneficiary
complaints about quality of services, timeliness of services, and
administrative problems. Such complaints, known as grievances, may
not be appealed outside the plan. In commenting on a draft of this
report, HCFA said that it is developing an additional set of
requirements for grievance processes.

6 Beneficiaries discharged from a hospital by their HMO may appeal
to peer review organizations organizations that include practicing
doctors and other health care professionals, under contract to the
federal government to monitor the care given to Medicare patients.

7 CHDR reviews plans' appeal decisions that are not wholly
favorable to the enrollee. An independent review of a plan's
adverse initial decision is required by 42 C. F. R. 417.614. 8 All
parties to the initial decision have a right to appeal. This
includes the member, a representative of the member, a legal
representative on behalf of a deceased member's estate, and any
other entity determined to have an appealable interest in the
proceeding, such as out- of- plan physicians or suppliers.

9 A member may appeal a denied service or payment for service even
if a notice is not issued. 10 This was the effective date for
Medicare+ Choice regulations, issued on June 26, 1998.

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 5

B-281220

health care services and within 60 calendar days if it is for
payment. 11 The plan representative considering the appeal must
not have been involved in making the initial decision. To make a
reconsidered decision, the plan representative reviews the initial
decision and all other evidence submitted by the beneficiary,
beneficiary representative, provider, and health plan.

If a plan upholds, in whole or part, its initial denial, it must
forward the case to CHDR for external review. 12 HCFA has modified
its contract with CHDR requiring CHDR to be held to the same time
standards as the plans for processing appeals. (Prior to the
change, CHDR had 30 days to consider the case, make its ruling,
and inform the beneficiary of its decision.) If CHDR upholds the
plan's denial, the beneficiary can request an additional appeal
before an ALJ, provided the services in question cost at least
$100. 13 A beneficiary may ask that the Social Security
Departmental Review Board review a denied ALJ appeal. If the board
declines to review the ALJ decision or denies the appeal and the
amount of the services in question is greater than $1,000, the
beneficiary may request a hearing in U. S. District Court. A
beneficiary who loses an appeal is responsible for the cost of any
disputed health care services that he or she obtained. Figure 1
shows the Medicare appeals process, step by step.

11 HCFA also established new processing time frames for initial
determinations. Plans must make these decisions within 14 calendar
days for request of health services and 30 calendar days for
payment of services. The time frames can be extended up to an
additional 14 calendar days, if such extension would be helpful to
the beneficiary.

12 For calendar years 1996 and 1997 and the first 7 months of
1998, CHDR received 5,543, 8,152, and 6,334 appeal cases,
respectively. 13 The beneficiary has 60 days from the date of
HCFA's reconsideration determination to request a hearing before
an ALJ.

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 6

B-281220 GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
Page 7

B-281220

Figure 1: Medicare Appeals Process

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 8

B-281220

Beneficiaries or Their Physicians Can Request an Expedited
Decision

Since August 28, 1997, HCFA has required managed care plans to
establish and maintain an expedited process covering both initial
decisions and internal appeals. Medicare beneficiaries can request
expedited decisions when they believe that waiting the standard
time for an initial decision or an appeal of the initial decision
could seriously jeopardize their health or

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 9

B-281220

life. If a beneficiary makes the request, the plan determines
whether the expedited process is warranted. If a physician makes
the request on behalf of a beneficiary or concurs with the
beneficiary's request, the plan must expedite its decision.
Generally, health plans must make the expedited decision within 72
hours following the request. 14 An expedited decision that is
adverse to the beneficiary must be forwarded to CHDR within 24
hours. 15 CHDR is required to process the expedited cases within
72 hours. 16 Figure 2 provides the time intervals for major events
in the process.

14 Certain exceptions allowed plans an extension of up to 10
additional working days. This was redefined to 14 calendar days,
effective July 27, 1998. 15 CHDR received 870 expedited appeal
cases in 1997 and 1,755 expedited appeal cases during the first 7
months of 1998. 16 Prior to August 1998, CHDR had up to 10 days to
process expedited cases.

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 10

B-281220

Figure 2: Elapsed Time for Major Events in the Appeals Process

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 11

B-281220

Beneficiaries' Limited Use of the Appeals Process May Understate
Dissatisfaction With HMOs' Initial Decisions

HMOs that responded to our survey reported receiving approximately
9 appeals annually per 1,000 Medicare members. 17 However, this
number may understate beneficiaries' dissatisfaction with HMOs'
initial decisions. First, dissatisfied beneficiaries may disenroll
and switch to another plan or fee- for- service instead of
appealing. Second, beneficiaries may be unfamiliar with their
appeal rights or the appeals process. Plans may not always issue
the required notices or may omit an explanation of beneficiaries'
appeal rights. In other cases, beneficiaries may not appeal
because the notices list nonspecific reasons for the denial.

Annual Appeals Per 1,000 Beneficiaries Varied Among HMOs

The number of annual appeals per 1,000 Medicare beneficiaries
varied among HMOs and may be rising. The 242 Medicare HMOs that
responded to our recent survey reported an average of about 9
appeals annually per 1,000 beneficiaries between January 1996 and
May 1998 (see table 1). Generally, plans overturned nearly three-
quarters of the requested appeals. Those not overturned were
submitted to CHDR for further review and consideration. Between
August 28, 1997, and December 31, 1997, plans expedited 861
appeals. 18 During the first 5 months of 1998, plans expedited
1,548 appeals.

Table 1: Medicare Risk HMO Internal Appeals, 1996 to May 1998

Year Number of HMOs a

Percentage of all risk HMO

enrollees Average

monthly enrollment

(millions) Total appeals

Annual number of appeals per 1,000

Medicare enrollees

1996 160 84 2.7 22,437 8.2 1997 223 85 3.9 31,844 8.1 1998 b 242
89 4.8 21,138 10.5 Note: Table reflects responses from 242 HMOs
that completed GAO's questionnaire on internal appeals.

a Number of HMOs that responded to our survey in 1998 and were
active in given year. b Includes first 5 months of 1998. Source:
GAO survey of Medicare risk HMOs active as of May 31, 1998.

17 In July 1998, we surveyed all (307) HMOs with active Medicare
enrollment as of May 31, 1998. Eighty percent of the HMOs,
representing about 5 million (89 percent) of the Medicare
beneficiaries enrolled in HMOs, responded to our questionnaire.
During 1996, 1997, and the first 5 months of 1998, these HMOs
reported receiving about 22,000, 32,000, and 21,000 appeals,
respectively. Although the number of appeals increased from 1996
to 1997, the number of managed care enrollees also increased.
Consequently, the average rate of appeals per 1,000 members was
approximately the same in both years.

18 About two- thirds of the plans responding to our survey
reported the number of requests received that they had expedited.
On average, these plans expedited about one quarter of the
requests.

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B-281220

The number of annual appeals per 1,000 Medicare beneficiaries
among HMOs ranged from 0 to 90. Over half of the plans reported
between 1 and 10 appeals per 1,000 beneficiaries. A number of HMOs
reported no appeals for each study year: 17 percent in 1996, 13
percent in 1997, and 9 percent in 1998. Nearly all of these HMOs
(87 percent) had low Medicare enrollment. There was no similar
pattern for plans with the highest appeal rates; they were spread
nearly evenly across all plan sizes. 19

The appeal rate may be rising. Plans reported just over 8 appeals
per 1,000 beneficiaries in 1996 and 1997, but annualized data from
the first 5 months of 1998 indicated more than 10 appeals per
1,000 beneficiaries. Aggregate appeals data may indicate potential
problems with a plan's appeals process, but additional information
is needed to assess whether a plan adequately performs this
function. A relatively low appeal rate may be the result of a
plan's low denial rate or members who are unaware of their appeal
rights. Conversely, a plan that denies many requests or that
actively educates members about their rights may experience a
relatively high appeal rate. Consequently, appeals data should be
considered in conjunction with other factors, such as the rates at
which CHDR overturns plans' appeal decisions and HCFA's
observations of plans' appeals process.

Some Beneficiaries May Disenroll Instead of Filing Appeals

The number of appeals may understate beneficiaries'
dissatisfaction with their HMO's initial decision if some
disenroll instead of appealing. Currently, beneficiaries may
disenroll and switch to another plan or Medicare fee- for- service
at the end of any month. As we have previously reported, many
Medicare HMOs experience high disenrollment rates. 20 The extent
to which beneficiaries choose to disenroll rather than appeal is
unknown. It is clear, however, that disenrollees report less
satisfaction with the care they received from their HMOs than
enrollees. According to a survey conducted by HHS' OIG,
disenrollees were much more likely than enrollees to say that
their primary HMO doctor failed to provide Medicare- covered
services. 21 The survey showed that 12 percent of the

19 We divided the plans into four equal groups based on the
Medicare beneficiary enrollment in each year data were reported.
For example, for 1998 data, the quartiles were (1) 7 to 2,357
members; (2) 2,358 to 8,135 members; (3) 8,136 to 21,200 members;
and (4) 21,201 to 250,366 members.

20 Medicare: Many HMOs Experience High Rates of Beneficiary
Disenrollment (GAO/HEHS-98-142, Apr. 30, 1998) and Medicare: HCFA
Should Release Data to Aid Consumers, Prompt Better HMO
Performance (GAO/HEHS-97-23, Oct. 22, 1996). Although some
disenrollment is likely caused by beneficiaries' concerns over the
care they received or their plans' unwillingness to provide
requested services, other factors, such as the benefit packages
offered by competing HMOs, likely play a role. GAO's data were
unable to identify beneficiaries' reasons for disenrolling.

21 HHS OIG, Beneficiary Perspectives of Medicare Risk HMOs, 1996
(OEI- 06- 95- 00430, Mar. 1998).

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 13

B-281220

disenrollees said that their doctors failed to provide covered
services, whereas, only 3 percent of enrollees made such an
assertion.

If some beneficiaries leave their plans instead of appealing
adverse decisions, the number of appeals may rise as BBA's lock-
in provisions take effect. Beginning January 1, 2002,
beneficiaries will generally be able to change their enrollment
decision only once each year outside the annual open enrollment
period. 22 In 2002, this change must occur within the first 6
months of the year. In subsequent years, the change must occur
within the first 3 months. After the disenrollment period ends (3
or 6 months), beneficiaries will be locked into their selected
plans for the remainder of the year.

HHS' Inspector General and Advocacy Groups Find Beneficiaries Are
Confused About Medicare Appeals Process

Studies by HHS' OIG and by the Medical Rights Center (MRC) 23
confirm the views of several advocacy group representatives that
beneficiaries are confused about the Medicare appeals process. 24
HHS' OIG reported in March 1998 that 27 percent of Medicare HMO
enrollees and 35 percent of disenrollees surveyed were uninformed
about their appeal rights 25 rates similar to those found by the
Inspector General in 1993.

The results of an analysis conducted by MRC are consistent with
the OIG's findings. MRC reported that 40 percent of the 179
beneficiaries who called the center between August 27, 1997, and
February 28, 1998, were confused about their appeal rights.
According to MRC officials, HMO physicians and customer service
staff sometimes compounded beneficiaries' confusion. For example,
MRC handled several cases where HMO customer service
representatives allegedly gave out misleading, incorrect, or no
information on beneficiaries' Medicare appeal rights.
Representatives of other advocacy groups reported similar
experiences and said that they believe many beneficiaries have
difficulty understanding the appeals process.

22 Exceptions are allowed for certain circumstances. For example,
individuals who, upon becoming eligible for part A at age 65,
enroll in a Medicare+ Choice plan may switch to a different plan
or fee- for- service at any time during the 12- month period
beginning on the effective date of enrollment.

23 MRC is a national not- for- profit organization that aims to
ensure that Medicare beneficiaries have access to quality,
affordable health care. 24 The advocacy groups are the American
Association of Retired Persons; Center for Medicare Advocacy,
Connecticut; Center for Health Care Rights, Los Angeles; and Legal
Assistance to the Elderly, San Francisco.

25 HHS OIG, Beneficiary Perspectives of Medicare Risk HMOs, 1996.
The Inspector General selected a random sample that included
enrollees who were enrolled as of June 1996 and disenrollees who
had disenrolled between March 1996 and June 1996 for reasons other
than death.

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B-281220

Denial Notices Are Sometimes Incomplete or Never Issued

Beneficiaries are supposed to be informed of their appeal rights
when they receive a written notice from their plan denying a
service or payment. 26 These notices are required to state that
the beneficiary has the right to appeal if he or she believes the
plan's initial determination is incorrect. The notices must also
tell the beneficiary where and when the appeal must be filed.
However, HCFA, OIG, and our own analysis of CHDR appeal cases
found numerous instances of incomplete or missing denial notices.

HCFA monitoring reviews indicate that some denial notices were not
issued and others failed to mention beneficiaries' appeal rights.
In 1997, HCFA performed 90 monitoring visits to health plans.
About 13 percent of the plans reviewed were cited for failing to
issue denial notices. Nearly one- quarter of the 90 plans were
cited for issuing denial notices that did not adequately explain
beneficiaries' appeal rights. Two studies by HHS' OIG provide
additional evidence that beneficiaries are not always informed of
their appeal rights. In one study, the OIG found that in 39 out of
144 appeal cases there was no evidence that the beneficiaries had
been sent the plans' initial decisions explaining their appeal
rights. 27 In another study, the OIG surveyed beneficiaries who
were enrolled or had recently disenrolled from a managed care
plan. 28 According to the results of a survey, 41 respondents
(about 10 percent) said that their health plan had denied
requested services. Of these, 34 (83 percent) said that they had
not received the required notice explaining the denial and their
appeal rights.

Similar deficiencies were found in the appeal cases reviewed at
CHDR. Of the 108 CHDR appeal cases reviewed, 29 5 contained denial
notices that failed to inform the beneficiary of his or her appeal
rights. Another 32 cases sent to CHDR by the plans lacked the
denial notices completely.

26 In addition, plans are required to explain members' appeal
rights in the marketing materials they distribute. 27 HHS OIG,
Medicare HMO Appeal and Grievance Processes, Review of Cases (OEI-
07- 94- 00283, Dec. 1996). 28 HHS OIG, Medicare HMO Appeal and
Grievance Processes, Beneficiaries' Understanding (OEI- 07- 96-
00281, Dec. 1996). 29 We selected these cases from completed
decisions at CHDR during the month of October 1998. We randomly
selected 27 cases from four case types: (1) expedited decisions
upheld by CHDR (459 cases), (2) expedited decisions overturned by
CHDR (159 cases), (3) nonexpedited decisions upheld by CHDR (1,772
cases), and (4) nonexpedited decisions overturned by CHDR (500
cases).

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Some Notices Do Not Indicate Specific Reasons for the Denial

HCFA requires that denial notices clearly state the specific basis
for denial. HCFA officials said that vaguely worded denial notices
hinder enrollees' efforts to construct compelling counterarguments
for their appeals. Also, vague notices may hinder beneficiaries
from appealing because they may be uncertain as to whether they
are entitled to the requested services.

Most notices we reviewed contained general, rather than specific,
reasons for the denial. In 53 of the 74 CHDR cases that contained
the required denial notices, the notices simply said that the
beneficiary did not meet the coverage requirements or contained
some other generic reason. It is unclear whether beneficiaries who
receive denial notices with nonspecific reasons are less likely to
submit written support for their position compared to
beneficiaries who receive more detailed notices. Beneficiaries had
submitted written support in only 14 of the CHDR appeal cases. 30

Reconsideration notices written by CHDR personnel provide much
greater detail than notices written by plan personnel. For
example, in one case, the health plan issued a notice of
noncoverage for skilled nursing facility (SNF) services, stating

you required skilled rehabilitation services P. T. eval. for
mobility + gait eval. for ADL's, speech eval. swallowing from 2/
11/ 98 and these services are no longer needed on a daily basis.
31

CHDR's letter to the beneficiary (upholding the HMO's denial)
stated the following:

The case file indicated that while [name] was making progress in
his therapy programs, his condition had stabilized and further
daily skilled services were no longer indicated. The physical
therapy notes indicate that he reached his maximum potential in
therapy. He had progressed to minimum assistance for bed mobility,
moderate assistance with transfers, and was ambulating to 100 feet
with a walker. The speech therapist noted that his speech was much
improved by 2/ 18/ 98 and that his private caregiver had been
instructed on safe swallowing procedures and will continue with
feeding responsibilities.

Representatives from several advocacy groups told us that in cases
brought to their attention, the denial notices were often general
and did

30 In one case, it was impossible to determine whether the
beneficiary had submitted a written argument. 31 P. T. stands for
physical therapy, eval. stands for evaluation, and ADL' stands for
activities of daily living.

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B-281220

not clearly explain why the beneficiary would not receive or
continue to receive a specific service. In August 1997, MRC
established a hotline for HMO appeals and analyzed all calls it
received during the first 6- month period (179). 32 MRC concluded
that the explanations found in most plans' denial notices were
unhelpful because of their generality for example, the services
were not medically necessary. 33

Notices of Discontinued Coverage Are Often Issued 1 Day Before
Services Are Stopped

HCFA regulations state that whenever plans discontinue services,
they must issue timely denial notices to beneficiaries. HCFA,
however, does not specify how much advance notice is required and
we found that many plans do not issue denial notices in what many
would reasonably consider timely. Although beneficiaries may
appeal denied services upon receiving notice, those who receive
little advance notice may not be able to continue to receive
services because of their potential financial liability. If the
beneficiary appeals and loses, he or she is responsible for the
cost associated with services received after the date specified in
the denial notice. The potential financial burden can be
substantial, especially if the denial involves SNF services.

In three of the four plans we visited, the general practice was to
issue denial notices the day before services were discontinued. We
reviewed a number of SNF discharge notices at three HMOs and often
found that the notices were mailed (usually by certified or
express mail) to the beneficiary's home instead of being delivered
to the facility where the beneficiary resided. In some cases, it
appeared that the beneficiary or his or her representative
received the notice a few days after the beneficiary had been
discharged. Ten of the 25 CHDR cases we reviewed also involved a
beneficiary or his or her representative receiving a discharge
notice after the beneficiary was discharged from the SNF. 34

The fourth plan we visited issued SNF discharge notices 3 days
prior to the discharge date. This lead time helped ensure that the
beneficiary received the notice before the discharge. It also
allowed more time for the beneficiary to file an expedited appeal
and receive a decision from the plan. Consequently, beneficiaries
in this plan who appeal and lose are less exposed to SNF costs
incurred during the appeals process.

32 The hotline operated for 2 hours a day, 4 days a week. At other
times, a caller was instructed to leave a message or seek
assistance from another organization listed on their denial
notice. 33 MRC, Systemic Problems With Medicare HMOs: Case Studies
From the Medicare Rights Center HMO Hotline (Sept. 1998). 34 There
were 27 cases involving SNF discharges, but 2 cases had
conflicting data.

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Officials in three plans indicated that when a beneficiary is
being considered for discharge, a nurse or discharge planner
probably would have discussed the issue with the beneficiary well
in advance of the discharge. Even when a beneficiary knows a
discharge is imminent, however, he or she cannot appeal until a
denial notice is officially issued. Officials from the plans we
visited told us that, in almost every instance, the decision to
discharge a beneficiary from a SNF is made several days before the
actual discharge date. Officials from all the plans agreed that,
in most instances, such notices could be issued several days prior
to the discharge date so that beneficiaries who wished to appeal
could receive an expedited appeal decision before the planned
discharge date.

HCFA's Oversight of Plans' Appeals Procedures Is Limited

HCFA's biennial monitoring of plans' appeals process focuses on
timeliness and administrative issues, but we found several
important weaknesses in the agency's monitoring procedures. For
example, HCFA's sampling of cases to determine whether
beneficiaries are appropriately informed of their appeal rights
likely misses beneficiaries who were not informed. HCFA's
monitoring also generally excludes the operations of HMO provider
groups that may be responsible for making denial decisions and for
issuing the required notices. HCFA officials believe that the
agency can improve in many of these areas, and in commenting on a
draft of this report, HCFA said that it has begun to address these
weaknesses. However, to date, HCFA has made little use of the
results of its HMO performance reviews to develop overall national
trends and improve the agency's oversight function.

HCFA's Monitoring Protocol Systematically Misses Beneficiaries Who
May Not Have Been Informed of Their Appeal Rights

To determine whether plans informed beneficiaries of their appeal
rights, HCFA's monitoring protocol requires agency staff to review
a sample of appeal cases. HCFA staff check these case files to
determine whether each contains a copy of the required denial
notice. However, it seems reasonable to assume that beneficiaries
who appeal denials are more likely to have been informed of their
rights than beneficiaries who do not appeal. Yet HCFA does not
check cases where services or payment for services were denied and
not appealed. HCFA might get a better indication of whether
beneficiaries were told of their rights if agency staff examined a
sample of denial notices from cases that were not appealed.

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HCFA and Plans Exercise Little Oversight of Administrative Tasks
Delegated to Provider Groups

Some health plans delegate the responsibility for deciding whether
to expedite initial decisions, issuing denial notices, and other
operating tasks to medical provider groups. For example, one plan
we visited had delegated the responsibility of issuing service and
payment denial notices, including paying claims, to approximately
250 provider groups with which it contracted. A plan official
stated that his plan has never reviewed service denials and does
not know how many services its provider groups have denied. The
plan has, however, recently developed a monitoring protocol to
review service denials and intends to implement it soon. According
to several HMO officials, this practice is common in California
and is increasing in other parts of the country.

Officials also said that HMOs typically exercise little or no
oversight over provider groups' operations and have difficulty
ensuring that groups adequately perform the delegated tasks. For
example, according to an official from another HMO, provider
groups on the West Coast expect plans to grant them the authority
to issue denial notices because they are at financial risk for the
services they provide. To contract with these groups, his plan
must delegate that authority even though the practice is not
desirable from his HMO's perspective. He said that provider groups
often do not send the plans copies of issued denial notices,
although the plans request them. The official estimated that his
plan receives only about 30 percent of the denial notices issued
by their provider groups. He added that his plan does not review
the notices it does receive.

Moreover, according to a HCFA official, HCFA does not generally
monitor HMO provider groups. Because provider groups may not
submit requested information to HMOs and HCFA does not normally
monitor provider groups directly, it is likely that no one reviews
many of the initial decisions including expedited decisions made
by these groups. A 1998 study done for HCFA noted that the
delegation of authority to provider groups is problematic because
health plans do not exercise sufficient control over the delegated
functions. 35 The report recommended that HCFA pay closer
attention to this issue.

HCFA Has Provided Limited Guidance to Plans on Expedited Appeals
Process

Although HCFA has provided plans with general guidance, such as
model language for denial notices, it has not produced specific
guidelines to ensure consistent implementation of the expedited
appeals process. Further, without clear guidelines on what should
be expedited, HCFA has

35 Bailit Health Purchasing, LLC, The Medicare Managed Care
Compliance Monitoring Program: Recommendations for Modification
and Improvement (Jan. 28, 1998).

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B-281220

no way of determining whether plans are expediting initial
decisions and appeals appropriately. HCFA has not produced
criteria or examples for HMOs to follow when deciding whether the
standard appeal time frames could seriously jeopardize a
beneficiary's health or life. In the absence of such criteria,
Medicare HMOs have a wide latitude to determine whether a
beneficiary's request for an initial decision or appeal should be
expedited.

Receiving no specific guidance from HCFA, several California HMO
and provider industry representatives formed a work group and
developed clinical criteria for expedited initial decisions and
appeals. In January 1998, the HCFA region responsible for Arizona,
California, and Nevada provided the work group's criteria to all
Medicare HMOs in those three states. HCFA officials said they are
not aware of similar efforts in other regions. We found, however,
that at least one Florida HMO had incorporated much of the
California work group's criteria into its own procedures possibly
because the HMO also operated in California.

Without better guidance from HCFA, some cases that should be
expedited may not be. In our review of cases sent to CHDR, we
examined 42 appeals involving denied services that HMOs had not
expedited. CHDR reviewers determined that seven (17 percent) of
these cases should have been expedited. (CHDR expedited these
cases for its own review process.)

HCFA Makes Little Use of Available Data for National Program
Management

Staff from HCFA's central and regional offices told us that the
agency has made little use of its monitoring reports as an overall
program management tool. Each report documents the results of
HCFA's biennial performance review of a plan and summarizes its
compliance with Medicare regulations. Aggregating the findings
from the individual monitoring reports could help HCFA monitor the
relative performance of plans, identify variations among regions,
and study national trends. However, when we requested all of the
1997 monitoring reports no one at HCFA's headquarters had a
complete set. We were told that we would have to request them from
each region.

Shortly after we requested the reports from the regions, the
Health Plan Purchasing and Administration Group in HCFA's central
office began collecting from the regional offices all 1996 and
1997 monitoring reports. According to HCFA officials, agency staff
are now analyzing the information in the reports.

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HCFA is planning to develop a health plan management system that
will provide information to central and regional office staff and
will aid plan and program oversight. The system will include
information on appeals. HCFA had expected to complete the data
design phase by now but has fallen behind schedule. According to
the project manager, the system will not be operational until late
1999 or early 2000.

HCFA Has Not Required Plans to Collect and Report Data on Appeals

The need for both HCFA and Medicare beneficiaries to have
information on HMO appeals is well recognized. In 1996, and again
in 1998, HHS' OIG recommended that HCFA require managed care plans
to report data on appeals, such as the number of cases, the number
resolved internally and externally, issues involved, and the time
needed to resolve cases. 36 Also, in implementing its expedited
process, HCFA is requiring plans to report data on expedited
appeals. Further, BBA requires plans to disclose information on
the number and the disposition of appeals to interested Medicare
beneficiaries.

On February 10, 1999, HCFA issued an operational policy letter
that establishes the guidance for managed care plans to follow in
collecting appeals data and making that information available to
Medicare beneficiaries. Plans will report the number of appeals
per 1,000 Medicare beneficiaries. Each plan's rate will be based
on its contract market. 37 Plans will begin collecting and
maintaining appeals data beginning April 1, 1999. Data collection
periods will be based on a rolling 12- month period. (The prior 6
months of data are added to the next 6 months of data in order to
come up with a 12- month data collection period.) The first 6-
month period will begin April 1, 1999, and end September 30, 1999.
Plans will report results from the first 6- month period on
January 1, 2000.

HCFA, however, has not provided guidance on the type of appeals
data plans should collect and report to HCFA. According to
officials in HCFA's central office, the agency has formed a work
group consisting of plan representatives, advocacy
representatives, and program officials to develop appeals data
requirements. HCFA expects to finalize these requirements later
this year. Meanwhile, some HMOs may be waiting to receive HCFA's
guidelines before they implement systems to track their appeals
data. Although all the plans that responded to our survey reported

36 HHS OIG, Medicare HMO Appeal and Grievance Process: Overview
(OEI- 07- 94- 00280, Dec. 1996), and Medicare's Oversight of
Managed Care: Monitoring Plan Performance (OEI- 01- 96- 00190,
Apr. 1998). 37 Contract market implies either reporting by
contract or by a market area within a contract. This determination
will be made by HCFA.

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B-281220

the total number of appeals upheld and overturned, only about two-
thirds were able to break down their appeals into more specific
service categories, such as nursing home care and emergency room
use.

Conclusions Medicare beneficiaries have access to a multilevel
appeals process that allows them to challenge HMO decisions to
deny services or payment for

services. Relatively few beneficiaries about 9 out of every 1,000
managed care enrollees appeal each year. Some beneficiaries may
not appeal, however, because they are unaware of their appeal
rights or confused about the process. Evidence from a variety of
sources HCFA monitoring reports, studies by HHS' OIG, and our
review of cases at plans and at CHDR indicate that plans do not
always inform beneficiaries of their appeal rights as required. In
some cases, denial notices cite nonspecific reasons for the
denial, making it more difficult for beneficiaries to challenge
their plan's decision. In other cases, beneficiaries may be
unnecessarily exposed to substantial health care costs because
notices are not issued in a timely fashion. Furthermore, the
agency has not issued specific guidance as to the types of cases
plans should expedite.

HCFA reviews plans' implementation of the appeals process, but its
monitoring protocol exhibits several weaknesses. For example, HCFA
does not know whether provider groups have satisfactorily
implemented the required appeals process because it exercises
little oversight over provider group operations. The type of cases
HCFA samples to determine whether beneficiaries were informed of
their appeal rights likely systematically misses beneficiaries who
were not informed. Further, the agency has not provided plans
guidance on the types of appeals data they should collect and
report to HCFA. HCFA agrees that it needs to strengthen its
oversight of health plans' appeals process and noted that the
agency has several initiatives under way.

Recommendations To help ensure that the appeals process provides
adequate protection to Medicare beneficiaries, the HCFA
Administrator should take the following

actions:  Provide more explicit denial notice instructions to
plans. Denial notices

should explain the coverage criteria and state the specific reason
or reasons why the beneficiary did not meet the criteria.

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B-281220

 Set specific timeliness standards for certain types of denial
notices, such as discontinued SNF care services, to allow
beneficiaries reasonable time to obtain an expedited appeal
decision.  Develop criteria for plans to use in determining when
initial decisions and

appeals should be expedited. To improve the agency's monitoring of
the appeals process, the HCFA Administrator should take the
following actions:

 Require each plan to collect sufficient information from its
provider groups so that HCFA staff can, during the course of a
normal biennial performance review, determine whether the plan and
its provider groups satisfactorily implemented the required
appeals process.  Require agency staff conducting performance
reviews to sample a number

of denied cases that were not appealed to determine whether
beneficiaries were informed of their appeal rights.  Use the data
the agency collects during plan performance reviews to

assess the relative performance of plans, and develop strategies
for better plan monitoring and program management.

To ensure that appeals data are available to HCFA and Medicare
beneficiaries, the Administrator should develop requirements for
the type and format of appeals data plans must collect and make
available.

Agency Comments and Our Evaluation

HCFA agreed with our finding that its oversight of health plans'
appeals process needs to be strengthened and generally agreed with
our recommendations. (See app. II for HCFA's written comments
regarding our recommendations.) The agency outlined several
initiatives it has recently undertaken to better protect
beneficiary rights. Some of these initiatives may be implemented
shortly; others are in the early planning stage.

HCFA expressed concern, however, about our recommendation that the
agency develop criteria to help plans determine when initial and
appeal decisions should be expedited. HCFA said that a further
refinement of the current general criteria might inadvertently
exclude unspecified standards. HCFA said that it would explore
possible options regarding the criteria, but that it would proceed
cautiously to avoid unanticipated problems. We disagree with the
premise that further refinement of the criteria would
inadvertently limit beneficiary access to expedited initial and
appeal decisions. As noted in this report, specific clinical
criteria have been developed and used by plans in at least one
HCFA region. HCFA could

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B-281220

develop specific criteria, to be implemented nationwide, that are
understood to be an elaboration of the current general criteria
and not a replacement for them.

In addition, HCFA provided several technical comments, which we
incorporated as appropriate.

As agreed with your office, unless you publicly announce the
contents earlier, we plan no further distribution of this report
until 1 day from the date of this letter. At that time, we will
send copies to the Honorable Donna Shalala, Secretary of HHS; the
Honorable Nancy- Ann Min DeParle, Administrator of HCFA; and
interested congressional committees and members. We will also make
copies available to others on request.

Please contact me at (202) 512- 7119 or James Cosgrove, Assistant
Director, at (202) 512- 7029 if you or your staff have any further
questions. This report was prepared by Cam Zola, Richard Neuman,
and Beverly Ross.

Laura A. Dummit Associate Director, Health Financing

and Public Health Issues

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 24

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 25

Contents Letter 1 Appendix I Scope and Methodology

28 Appendix II Comments From the Health Care Financing
Administration

30 Table Table 1: Medicare Risk HMO Internal Appeals, 1996 to May
1998 12 Figures Figure 1: Medicare Appeals Process 8

Figure 2: Elapsed Time for Major Events in the Appeals Process 11

Abbreviations

ALJ administrative law judge BBA Balanced Budget Act of 1997 CHDR
Center for Health Dispute Resolution HCFA Health Care Financing
Administration HHS Department of Health and Human Services HMO
health maintenance organization MRC Medical Rights Center OIG
Office of Inspector General SNF skilled nursing facility

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 26

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 27

Appendix I Scope and Methodology

To obtain information on plan- level appeals handled by HMOs
during 1996, 1997, and the first 5 months of 1998, we surveyed all
(307) Medicare HMOs that were active as of May 31, 1998. We
obtained responses from 250 plans (81.4 percent).

We visited three judgmentally selected HMOs one in California and
two in Florida. We selected these plans based on (1) geographic
location, (2) high 1997 disenrollment rates, and (3) high Medicare
enrollments. Our visit to one Florida HMO coincided with a
monitoring visit by HCFA's region IV staff. During our visits, we
discussed the appeals process with plan officials and reviewed a
limited number of cases at three of the locations. The cases
included standard appeals and expedited appeals that were upheld
and overturned at the plan level within the 6 months prior to our
visit. Each case reviewed was discussed with a plan official
responsible for the plan's appeals process. In addition, we made a
site visit to an HMO in Maryland during a HCFA monitoring visit.
Our visit to the Maryland HMO was limited to overseeing the
monitoring team's review of appeal cases and several discussions
with plan officials.

We visited the two HCFA regional offices (region IX in San
Francisco, California, and region IV in Atlanta, Georgia)
responsible for the three plans we visited. We discussed the
appeals process and the monitoring effort with appropriate
officials in each region. We also spoke with regional personnel in
HCFA's region X about the appeals process and HCFA's monitoring
effort and results. In addition, we obtained from HCFA a summary
spreadsheet that showed all the monitoring reports completed in
1997 and summarized plan compliance with Medicare requirements.
From this list, we selected and reviewed the monitoring reports of
plans that indicated deficiencies in the categories related to the
appeals process, denial notices, or both.

With assistance from CHDR we randomly selected and reviewed 108
appeal cases that had been adjudicated by CHDR in 1998 and had not
been sent to storage as of October 1998. We developed a data
collection instrument and specific criteria for evaluating the
case file information. A CHDR analyst, who reviewed each case and
recorded the review results, used this instrument and criteria. We
reviewed the results of over half of the 108 cases to ensure the
data were recorded accurately and met our evaluation criteria.

We discussed HCFA's appeal policy and practice with HCFA officials
and representatives from five advocacy groups representing
Medicare

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 28

Appendix I Scope and Methodology

beneficiaries in health plans. In addition, we reviewed a number
of HHS OIG reports covering several aspects of Medicare's appeals
process in HMOs. Also, we reviewed a report done by the Medicare
Rights Center that discussed systemwide problems with Medicare
HMOs.

Our office of General Counsel reviewed the results of a class
action lawsuit and the resulting appeal by HCFA before the 9th U.
S. Circuit Court of Appeals.

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 29

Appendix II Comments From the Health Care Financing Administration

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 30

Appendix II Comments From the Health Care Financing Administration

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Appendix II Comments From the Health Care Financing Administration

GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights Page 32

Appendix II Comments From the Health Care Financing Administration

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Appendix II Comments From the Health Care Financing Administration

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Appendix II Comments From the Health Care Financing Administration

(101751) GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
Page 35

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