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.	697	701	216	30.8%
Americhoice of NY, Inc.	0	0	0	0.0%
Atlantis Health Plan, Inc.	298	282	105	37.2%
CDPHP	464	464	150	32.3%
CIGNA Healthcare of NY, Inc.	148	163	80	49.1%
Community Blue (HealthNow)	480	485	179	36.9%
Empire HealthChoice HMO, Inc.	258	254	87	34.3%
Excellus Health Plan, Inc.	1,416	1,449	539	37.2%
GHI HMO Select, Inc.	279	271	150	55.4%
Health Net of NY, Inc.	1,617	1,664	552	33.2%
HIP HMO	49	91	63	69.2%
Independent Health Association, Inc. (IHA)	205	210	135	64.3%
MVP Health Plan, Inc.	199	200	42	21.0%
Oxford Health Plans of NY, Inc.	4,892	4,950	1,961	39.6%
Rochester Area HMO, Inc. (Preferred Care)	177	179	81	45.3%
Total	11,179	11,363	4,340	Avg.=38.2%

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 2007.

• Number of closed appeals - Internal appeals that the HMO was able to reach a decision on by the close of 2007.

• 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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