Many states require that plans inform members about grievance procedures at least upon enrollment and sometimes annually. Timeliness, Decisionmaking Process, and Communication Are Important to a Complaint and Appeal System

A number of elements have been identified by regulatory, consumer, and industry groups as being important to a complaint and appeal system. These elements fall into three general categories: timeliness, integrity of the decisionmaking process, and effective communication with members. Several nationally recognized groups have developed guidelines for complaint and appeal systems. HMOs Had Most of the Important Elements, but Two Were Commonly Lacking

The HMOs in our review had most of the 11 elements identified by the groups in our study as being important to complaint and appeal systems, although they varied considerably in the mechanisms adopted to meet them. The extent to which HMOs in our study implement the policies they reported to us, however, is unknown. Not all 38 HMOs in our study, however, provided data on each of the elements. Consumer Groups Expressed Concerns Regarding Conflict of Interest and Communication Difficulties

Although the majority of HMOs’ complaint and appeal systems included most of the important elements, consumer advocates expressed concern that such systems are not fully meeting the needs of enrollees. Advocates specifically noted the lack of an independent, external review of plan decisions on appeals and noted members’ difficulty in understanding how to use complaint and appeal systems. There is limited experience with external review systems for HMO members. Complaint and Appeal Data Are Neither Comparable Nor Accessible

Publicly available data on the number and types of complaints and appeals, if defined and collected in a consistent fashion, could enhance oversight, accountability, and market competition. Such information would offer regulators, purchasers, and individual consumers a better opportunity to evaluate the relative performance of health plans. Data Collection and Documentation Systems Lack Uniformity, Making Comparisons Difficult

We asked HMOs to provide us with the number of complaints and appeals received from commercial members in 1996 and the nature of the complaints and appeals. HMOs Report That Complaint and Appeal Data Help Target Problem-Solving Efforts

All HMOs in our study told us that they analyze complaint and appeal data to identify systemic problems that the plan needs to address. HMOs generally reported using complaint and appeal data, together with data from other sources, in several ways: to make changes to the plan itself (such as changes to benefits or plan processes) or to promote change in members’ behavior and providers’ behavior. Better communication and information disclosure could improve the complaint and appeal process for the benefit of HMO members and plans. For example, ombudsman programs might be an alternative way to facilitate consumer knowledge about, and use of, these systems. Additional copies are $2 each.
Why GAO Did This Study

Pursuant to a congressional request, GAO examined: (1) what elements are considered important to a system for processing health maintenance organization (HMO) member complaints and appeals; (2) the extent to which HMOs' complaint and appeal system contain these elements; (3) what concerns consumers have regarding HMO complaint and appeal systems; (4) what information is available on the number and types of complaints and appeals HMOs receive from their members; and (5) how, if at all, HMOs use their complaint and appeal data.

What GAO Found

GAO noted that: (1) a majority of HMOs in GAO's study incorporated most criteria considered important for complaint and appeal systems, however, consumer advocates remain concerned that complaint and appeal systems do not fully meet member needs; (2) additionally, HMOs in GAO's study do not uniformly collect and report data on the complaints and appeals they receive to health care regulators, purchasers, or consumers; (3) nationally recognized regulatory, consumer, and industry groups have identified elements that are important to an enrollee complaint and appeal system; (4) 11 elements were identified by at least 2 of these groups and fall into 3 general categories: timeliness, integrity of the decisionmaking process, and effective communication with members; (5) the policies and procedures at the 38 HMOs in GAO's review contained most of the 11 important elements, although they varied considerably in the mechanisms adopted to meet them; (6) the lack of an independent, external review of plan decisions and the difficulty in understanding how to use plan complaint and appeal systems were of particular concern to consumer advocacy groups, who contend that plans' systems, therefore, do not adequately serve the needs of plan enrollees; (7) however, consumer concerns about the impartiality of HMO decisionmakers could be addressed by using independent, external review systems for HMO members; (8) consumer concerns about the difficulty in understanding how to use complaint and appeal systems might be addressed by revising written plan materials, which are often difficult to understand; (9) additionally, although experience to date is limited, such concerns are being addressed by ombudsman programs in some parts of the country; (10) publicly available data on the number and types of complaints and appeals, if consistently defined and uniformly collected, can enhance oversight, accountability, and market competition; (11) comparative data would provide regulators, purchasers, and individual consumers with a view of members' relative satisfaction with health plans, thereby supplementing other performance indicators; (12) all HMOs in GAO's study stated that they review complaint and appeal data to identify problems that the plan needs to address; and (13) several HMOs reported using complaint and appeal data, together with data from other sources, to make changes in benefits and plan processes, and to attempt changes in member and provider behavior as well.