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Do HMOs pay claims on time?

Understanding the Table

Current performance area: Prompt Pay Complaints
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
  Sort Columns by: HMO or RANK
HMO Rank Total
Total Prompt
Pay Complaints
Upheld Prompt
Pay Complaints
(Millions $)
Prompt Pay
Complaint Ratio
Aetna Health 11 485 282 113 $779.8 0.145
Atlantis1 -- -- -- -- -- --
CDPHP 3 82 24 2 $651.1 0.003
CIGNA 12 80 40 24 $117.2 0.205
Community Blue (HealthNow) 6 86 17 8 $1,037.5 0.008
Empire HealthChoice 7 689 302 42 $1,819.3 0.023
Excellus 5 134 28 10 $1,893.3 0.005
GHI-HMO Select 10 133 53 17 $132.5 0.128
Health Net of NY 14 766 604 266 $437.8 0.608
HIP 9 1,536 946 445 $4,127.6 0.107
IHA 1 27 4 0 $586.9 0.000
MDNY 15 271 249 230 $93.8 2.451
MVP Health Plan 4 111 28 3 $944.3 0.003
Oxford 8 1,195 476 132 $1,928.8 0.068
Rochester Area HMO (Preferred Care) 2 18 0 0 $321.6 0.000
UnitedHealthcare of NY 13 59 17 13 $28.6 0.455
Total   5,672 3,070 1,305 14,900.7 Avg.=0.281

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

You will find information about prompt pay complaints against HMOs that were reviewed and closed by the New York State Insurance Department in the year 2006. New York law requires that all HMOs pay providers and members within 45 days of receipt of an undisputed claim for health care services.

The Insurance Department reviews each complaint, then decides if the HMO is at fault and needs to remedy the problem. An upheld prompt pay complaint occurs when the Department agrees with the member or provider that a payment was late (or that the HMO made a late decision not to pay the claim).

The table ranks HMOs by their prompt pay complaint ratio from best (lowest prompt pay ratio) to worst (highest prompt pay ratio). A better ranking means that the HMO had fewer upheld complaints relative to its size. HMOs with a larger premium typically have more members and therefore, more complaints than smaller HMOs. For each HMO, the table will tell you:

  • Prompt Pay Complaints Rank - HMOs ranked by their prompt pay complaint ratio from best (lowest ratio) to worst (highest ratio). A better ranking means that the HMO had fewer upheld complaints relative to its size.

  • Total Complaints to NYSID - Total complaints closed by NYSID in 2006. Complaints to the Insurance Department typically involve issues concerning payment, reimbursement, coverage, benefits, rates and premiums.

  • Total Prompt Pay Complaints - Total number of prompt pay complaints closed by NYSID in 2006.

  • Upheld Prompt Pay Complaints - Number of closed prompt pay complaints in 2006 where NYSID agrees with the consumer or provider.

  • Premium* - Dollar amount of premiums generated by a HMO in New York during 2006. Premiums are used in calculating the complaint ratio so that different sized HMOs can be compared fairly.

  • Prompt Pay Complaint Ratio - Number of upheld prompt pay complaints divided by a HMO's total annual premium.

* Premium and Membership data exclude Medicare and Medicaid.

Keep in mind...

Large HMOs may receive more complaints because they serve more people and pay more claims than smaller HMOs.

The NYSID has established a dedicated hotline for consumers and providers to file prompt pay complaints at 1‑800‑358‑9260.

The Prompt Pay Complaints category is 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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