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Do HMOs pay claims on time?
Understanding the Table
Current performance area: Prompt Pay Complaints
Compare: Selected HMOs
Source: NYSID, 2008
Plans are listed in alphabetical order.
|
| HMO |
|
|
|
|
|
|
| Aetna Health Inc. |
10 |
548 |
157 |
65 |
$635.9 |
0.1022 |
| Atlantis Health Plan |
12 |
148 |
98 |
82 |
$66.1 |
1.2406 |
| CDPHP |
1 |
86 |
16 |
0 |
$648.9 |
0.0000 |
| Community Blue (HealthNow) |
7 |
91 |
68 |
31 |
$471.8 |
0.0657 |
| Empire HealthChoice HMO, Inc. |
6 |
742 |
391 |
116 |
$1,775.3 |
0.0653 |
| Excellus Health Plan, Inc. (HMO) |
5 |
128 |
29 |
14 |
$847.6 |
0.0165 |
| GHI HMO Select, Inc. |
13 |
355 |
302 |
177 |
$86.5 |
2.0466 |
| Health Net of NY, Inc. |
8 |
301 |
146 |
34 |
$465.0 |
0.0731 |
| HIP HMO |
11 |
1,170 |
406 |
406 |
$2,351.9 |
0.1726 |
| Independent Health Association, Inc. (IHA) |
3 |
21 |
3 |
1 |
$485.6 |
0.0021 |
| MVP Health Plan, Inc. |
4 |
74 |
25 |
2 |
$861.6 |
0.0023 |
| Oxford Health Plans of NY, Inc. |
9 |
1,360 |
698 |
123 |
$1,342.8 |
0.0916 |
| Rochester Area HMO, Inc. (Preferred Care) |
2 |
1 |
0 |
0 |
$385.3 |
0.0000 |
 |
| Total |
|
5,025 |
2,182 |
986 |
9788.4 |
Avg. = 0.1007 |
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 2008. 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 2008. 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 2008.
Upheld Prompt Pay Complaints - Number of closed prompt pay complaints in 2008 where NYSID agrees with the consumer or provider. Premium* - Dollar amount of premiums generated by a HMO in New York during 2008. 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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