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How do HMOs respond to grievances?

Understanding the Table

Current performance area: Grievances
Compare: Selected HMOs
Source: NYSID, 2006

Plans are listed in alphabetical order.

Click here for the pdf version of the table
Access to Care and ServiceStaying Healthy and Living with IllnessQuality of ProvidersGrievances
ComplaintsPrompt Pay ComplaintsInternal AppealsExternal Appeals
HMO Filed Grievances Closed Grievances1 Upheld Grievances Reversed Grievances Grievance Reversal Rate
Aetna Health 772 741 496 245 33%
Atlantis2 -- -- -- -- --
CDPHP 1,705 1,696 518 1,178 69%
CIGNA 363 353 138 215 61%
Community Blue (HealthNow) 917 932 433 499 54%
Empire HealthChoice 673 681 543 138 20%
Excellus 1,344 1,300 979 321 25%
GHI-HMO Select 354 361 122 239 66%
Health Net of NY 1,701 1,532 678 884 58%
HIP 1,205 1,144 420 724 63%
IHA 174 171 67 104 61%
MDNY 369 386 207 179 46%
MVP Health Plan 374 341 267 74 22%
Oxford 5,704 5,624 2,969 2,655 47%
Rochester Area HMO (Preferred Care) 273 284 161 123 43%
UnitedHealthcare of NY 38 38 20 18 53%
Total 15,966 15,584 8,018 7,596 Avg.=48%

Closed grievances can exceed filed grievances in 2006 because closed grievances also include grievances filed prior to 2006.
Atlantis Health Plan has the minimum premium required to report data, but did not report the data by the deadline, so the data are not reported in this Guide.

Understanding the Table

A grievance is a complaint to an HMO by a member or provider about an action or decision. Common grievances include trouble getting referrals to specialists and disagreements over benefit coverage. Medical necessity issues are not grievances; they are handled as internal appeals.

By State law, New York HMOs are required to have a system in place for responding to their members' concerns. A committee within the HMO reviews the grievance and makes a decision.

For each HMO, the table will tell you:

  • Filed Grievances - Number of grievances submitted to the HMO.

  • Closed Grievances - Number of grievances the HMO was able to make a decision on by the end of the reporting period.

  • Upheld Grievances - Number of closed grievances where the HMO stood by its original decision and did not decide in favor of the member or provider.

  • Reversed Grievances - Number of closed grievances where the HMO changed its initial decision and decided in favor of the member or provider.

  • Reversal Rate - Percentage of grievances that an HMO decided in favor of the consumer or provider. Example: A 30% reversal rate indicates that in three out of ten grievances, the HMO changed its initial decision and decided in favor of the consumer or provider.

Keep in mind...

You should pay specific attention to an HMO that has a very high or very low reversal rate.

  • A low reversal rate may indicate that the HMO is making its decisions correctly, so fewer of its decisions require reversal. However, an unusually low reversal rate may mean that the HMO is not giving appropriate reconsideration to its initial decisions.
  • A high reversal rate may indicate that an insurer's grievance process is responsive to members. However, an unusually high reversal rate may indicate that the HMO's process for making initial decisions is flawed.

Please note the following:

  • There is no ideal reversal rate.
  • The number of grievances filed may be higher for HMOs that actively promote the grievance process to members.

Grievances are only one of eight performance areas presented.


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State of New York
David A. Paterson
State of New York
Department of Insurance
Eric R. Dinallo
Superintendent of Insurance
State of New York
Department of Health
Richard F. Daines, M.D.
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