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.	848	876	281	595	32.1%
Americhoice of NY, Inc.	0	0	0	0	0.0%
Atlantis Health Plan, Inc.	417	405	193	212	47.7%
CDPHP	1,966	1,977	1,271	706	64.3%
CIGNA Healthcare of NY, Inc.	176	199	103	96	51.8%
Community Blue (HealthNow)	668	678	351	327	51.8%
Empire HealthChoice HMO, Inc.	574	553	81	472	14.6%
Excellus Health Plan, Inc.	2,042	2,081	592	1,489	28.4%
GHI HMO Select, Inc.	199	200	104	96	52.0%
Health Net of NY, Inc.	2,974	3,123	1,772	1,351	56.7%
HIP HMO	1,701	1,693	1,050	643	62.0%
Independent Health Association, Inc. (IHA)	687	685	292	393	42.6%
MVP Health Plan, Inc.	209	238	84	154	35.3%
Oxford Health Plans of NY, Inc.	9,883	10,057	5,543	4,514	55.1%
Rochester Area HMO, Inc. (Preferred Care)	199	210	58	152	27.6%
Total	22,543	22,975	11,775	11,200	Avg.=52.2%

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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