United States Government Publishing Office publisher pbl distributor dst United States Government Accountability Office Health, Education, and Human Services Division author aut Government Organization text government publication eng GAOREPORTS Legislative Agency Publications gao legislative 2010-08-12 U.S. Government Printing Office 1999-04-12 monographic deposited born digital 39 p. GA 1.13:HEHS-99-68 https://www.govinfo.gov/app/details/GAOREPORTS-HEHS-99-68 P0b002ee180383133 f:he99068 DGPO 2010-08-12 2011-03-24 GAOREPORTS-HEHS-99-68 machine generated eng fdlp REPORT GAOREPORTS-HEHS-99-68 HEHS-99-68 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 Medicare Program Letter Report HEHS 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.<p/>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. https://www.govinfo.gov/content/pkg/GAOREPORTS-HEHS-99-68/html/GAOREPORTS-HEHS-99-68.htm https://www.govinfo.gov/content/pkg/GAOREPORTS-HEHS-99-68/pdf/GAOREPORTS-HEHS-99-68.pdf GAO/HEHS-99-68 https://www.govinfo.gov/app/details/GAOREPORTS-HEHS-99-68 Letter Report GAO/HEHS-99-68; Medicare Managed Care: Greater Oversight Needed to Protect; 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 Medicare Program