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What are utilization review appeals?
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| Click here for the pdf version of the table |
| HMO | Filed Appeals | Closed Appeals1 | Reversed Appeals | Appeals Reversal Rate | ||||
| Aetna Health | 673 | 658 | 286 | 43% | ||||
| Atlantis2 | -- | -- | -- | -- | ||||
| CDPHP | 420 | 418 | 166 | 40% | ||||
| CIGNA | 367 | 375 | 188 | 50% | ||||
| Community Blue (HealthNow) | 682 | 667 | 289 | 43% | ||||
| Empire HealthChoice | 198 | 198 | 61 | 31% | ||||
| Excellus | 970 | 954 | 326 | 34% | ||||
| GHI-HMO Select | 199 | 205 | 121 | 59% | ||||
| Health Net of NY | 2,232 | 2,256 | 778 | 34% | ||||
| HIP | 112 | 65 | 33 | 51% | ||||
| IHA3 | 50 | 49 | 35 | 71% | ||||
| MDNY | 305 | 323 | 138 | 43% | ||||
| MVP Health Plan | 236 | 241 | 41 | 17% | ||||
| Oxford | 4,684 | 4,675 | 2,133 | 46% | ||||
| Rochester Area HMO (Preferred Care) | 139 | 151 | 47 | 31% | ||||
| UnitedHealthcare of NY | 13 | 13 | 7 | 54% | ||||
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| Total | 11,280 | 11,248 | 4,649 | Avg.=43% | ||||
1 |
Closed internal appeals can exceed filed UR appeals in 2006 because closed internal appeals also include UR appeals 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. |
3 |
Includes appeals for the Art. 43 managed care contracts. |
Understanding the Table
An internal appeal or utilization review (UR) appeal occurs when a consumer asks an HMO to reconsider its refusal to pay for a medical service the insurer considers experimental, investigational, or not medically necessary. HMOs are required to have medical professionals review appeals. Common internal appeals involve the medical necessity of hospital admissions, the length of hospital stays, and the use of certain medical procedures. For each HMO, the table will tell you:
Number of filed appeals - Internal appeals submitted to the HMO by consumers in 2005.
Number of closed appeals - Internal appeals that the HMO was able to reach a decision on by the close of 2005.
Number of reversed appeals - Internal appeals that the HMO decided in favor of the consumer. If an internal appeal decision is reversed on appeal, the HMO agrees to pay for the service or procedure.
Reversal rate - Percentage of appeals decided in favor of the consumer; i.e., the HMO agrees to pay for the service.
Keep in mind...
You should pay specific attention to a HMO that has a very high or very low reversal rate.
- A low reversal rate may indicate that the HMO is making its initial decisions correctly, so fewer of these decisions require reversal. However, an unusually low reversal rate may indicate that the HMO is not giving appropriate reconsideration to its initial decisions.
- A high reversal rate may indicate that an HMO's appeals process is responsive to consumers. However, an unusually high reversal rate may indicate that the HMO's process for making initial medical necessity decisions is flawed.
Please note the following:
- There is no ideal reversal rate.
- The number of internal appeals filed may be higher for HMOs that actively promote the appeals process and encourage members to appeal denied services.
The Utilization Review Appeals Category is only one of eight performance areas presented.
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