Access to Care and Service Staying Healthy and Living with Illness Quality of Providers Grievances

Complaints Prompt Pay Complaints Internal Appeals External Appeals

HMO	Filed Grievances	Closed Grievances1	Upheld Grievances	Reversed Grievances	Grievance Reversal Rate
Aetna Health Inc.	698	701	230	471	32.8%
Atlantis Health Plan	126	123	41	82	33.3%
CDPHP	1,468	1,486	945	541	63.6%
Community Blue (HealthNow)	433	435	212	223	48.7%
Empire HealthChoice HMO, Inc.	560	567	157	410	27.7%
Excellus Health Plan, Inc. (HMO)2	1,607	1,623	521	1,102	32.1%
GHI HMO Select, Inc.	187	189	90	99	47.6%
Health Net of NY, Inc.3	2,794	2,678	1,227	1,451	45.8%
HIP HMO	1,506	1,539	959	580	62.3%
Independent Health Association, Inc. (IHA)2	327	321	119	206	37.1%
MVP Health Plan, Inc.	150	151	66	85	43.7%
Oxford Health Plans of NY, Inc.3	11,936	11,708	5,845	5,863	49.9%
Rochester Area HMO, Inc. (Preferred Care)	174	201	154	47	76.6%
Total	21,966	21,722	10,566	11,160	Avg. = 48.6%

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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