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 1998-05-19 monographic deposited born digital 14 p. GA 1.13:T-HEHS-98-173 https://www.govinfo.gov/app/details/GAOREPORTS-T-HEHS-98-173 P0b002ee180391945 f:he98173t DGPO 2010-08-12 2011-03-28 GAOREPORTS-T-HEHS-98-173 machine generated eng fdlp REPORT GAOREPORTS-T-HEHS-98-173 T-HEHS-98-173 Health maintenance organizations Information disclosure Consumer protection Health care planning Written communication Statistical data Health care programs Medicare Health Maintenance Organizations Program Testimony HEHS 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.<p/>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. https://www.govinfo.gov/content/pkg/GAOREPORTS-T-HEHS-98-173/html/GAOREPORTS-T-HEHS-98-173.htm https://www.govinfo.gov/content/pkg/GAOREPORTS-T-HEHS-98-173/pdf/GAOREPORTS-T-HEHS-98-173.pdf GAO/T-HEHS-98-173 https://www.govinfo.gov/app/details/GAOREPORTS-T-HEHS-98-173 Testimony GAO/T-HEHS-98-173; HMO Complaints and Appeals: Plans' Systems Have Most Key Elements, but Consumer Concerns Remain; Health maintenance organizations Information disclosure Consumer protection Health care planning Written communication Statistical data Health care programs Medicare Health Maintenance Organizations Program