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 Appeals	Closed Appeals1	Reversed Appeals	Appeals Reversal Rate
Aetna Health Inc.2	498	488	195	40.0%
Atlantis Health Plan	376	375	128	34.1%
CDPHP3	454	452	153	33.8%
Community Blue (HealthNow)	252	230	72	31.3%
Empire HealthChoice HMO, Inc.	224	222	72	32.4%
Excellus Health Plan, Inc. (HMO)	784	798	401	50.3%
GHI HMO Select, Inc.	194	205	114	55.6%
Health Net of NY, Inc.	1,154	1,161	322	27.7%
HIP HMO	65	60	31	51.7%
Independent Health Association, Inc. (IHA)	193	190	114	60.0%
MVP Health Plan, Inc.	195	193	29	15.0%
Oxford Health Plans of NY, Inc.	2,149	2,108	784	37.2%
Rochester Area HMO, Inc. (Preferred Care)	145	146	29	19.9%
Total	6,683	6,628	2,444	Avg. = 36.6%

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, not medically necessary or for HMO members, an out-of-network service. 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 2008.

• Number of closed appeals - Internal appeals that the HMO was able to reach a decision on by the close of 2008.

• 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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