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How do HMOs respond to grievances?
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| Click here for the pdf version of the table |
| 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% |
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| Total | 15,966 | 15,584 | 8,018 | 7,596 | Avg.=48% |
1 |
Closed grievances can exceed filed grievances in 2006 because closed grievances also include grievances filed prior to 2006. |
2 |
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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