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A. Jurisdiction and Responsibility for Consumer Complaints Systems
In Maryland two agencies - the Maryland Insurance Administration and the Health Education and Advocacy Unit in the Office of the Attorney General - have the major role in managing health insurance complaints, while the Health Care Access and Cost Commission produces comparative report card information on HMOs.
The Maryland Insurance Administration (MIA) is theoretically the first point of entry for all consumer complaints on health insurance. Regulators noted that the MIA is essentially the "pulse" of the industry. It is a regulatory body whose function is to check whether insurance plans are in compliance with statutes, their contractual obligations and various rules including the setting of rates. The MIA does not represent either insurance plans or consumers. Maryland law also allows providers to file complaints.
As of 1 January 1999 the new "Appeals & Grievances" Law took effect in Maryland. Grievances are internal complaints filed by consumers directly with their health plan challenging a plan's adverse decision to deny services based on medical necessity. As such, grievances are a subset of the total complaints about health insurance. Section B provides further information on the protocols specifically for management of grievances across the MIA and the Health Education and Advocacy Unit (HEAU) in the Office of the Attorney General. The jurisdiction and management of health insurance complaints generally is described below.
Occasionally, the MIA and the HEAU may be involved in managing the same complaint. Sometimes this occurs because consumers make multiple calls to state agencies. In other cases, the MIA may refer on a complaint to the HEAU for issues that fall outside its regulatory reach, but also retain the complaint to deal with other issues under its purview. The HEAU provides quarterly complaints reports to the MIA using compatible fields, but the data presented is non-identifying.
Unlike the MIA's regulatory compliance approach to complaints management, the HEAU (established in 1987) views its role as "problem solving for consumers". As such, it often gets the difficult cases which fall outside the regulatory scope of other agencies. The HEAU examines legislation which may be relevant in achieving complaint resolution. However unlike MIA's enforcement activities which are dependent upon the law, the HEAU undertakes mediation which can be successful in complaint resolution, even in the absence of specific legislation. Being able to move beyond the legislation is one factor considered important by HEAU staff in helping to assist consumers. It allows the HEAU to focus on consumer problems (a front-of house approach) and then work creatively with insurance plans to seek satisfactory resolution.
The HEAU does not have regular formal meetings with other agencies involved in complaints management, but liaises informally through telephone contacts. Staff believe that the HEAU operates somewhat like an ombudsman program, with no obvious powers lacking due to the absence of formal legislation establishing an ombudsman program. Unlike the MIA which remains neutral, the HEAU has a strong consumer advocacy focus.
The Maryland Department of Health and Mental Hygiene (DHMH) has primary responsibility for HMO quality complaints, with such complaints referred on by the MIA. Similar to the interaction between the MIA and the HEAU, the MIA and the DHMH may jointly handle a complaint if there are both quality and other issues. The MIA and the DHMH have signed a Memorandum of Understanding setting out their agreed roles and responsibilities (Attachment 1).
Provider licensing boards which fall under the Department of Health and Mental Hygiene also handle complaints about specific provider groups. In the late 1980s the HEAU established Memorandums of Understanding (MOUs) with some of these Boards, governing the way in which they would jointly operate and manage complaints. The HEAU continues to operate under the referral procedures initially established in these MOUs.
Currently the provider boards deal largely with quality of care issues and generally refer charging complaints to the HEAU. The Boards have to be careful in handling any financial complaints as there may be antitrust issues due to their governance and organizational structures. The HEAU refers some complaints (e.g. alleged molestation) to the relevant provider boards. The Boards tend to limit their operations to complaints where they have regulatory authority.
Medicare and Medicaid Complaints
The HEAU takes on a "translator" role for people who call with complaints involving Medicare and Medicaid. Common complaints for Medicaid beneficiaries involve billing issues. In some cases, the HEAU will directly answer the question, including contacting the relevant agency (HCFA(now known as CMS) for Medicare and the Maryland Department of Health and Mental Hygiene for Medicaid) on behalf of the complainant. In other cases the HEAU attempts to ensure that the complainant only has one more call to make, by identifying for complainants the correct person with whom they should speak.
The MIA liaises with relevant agencies via meetings and telephone calls on Medicare and Medicaid complaints. One advantage of MIA involvement is that it can issue penalties.
ERISA Complaints
The MIA and the legislature are aware that large numbers of Maryland residents are insured through self-funded plans and outside their jurisdiction. The MIA also does not have jurisdiction over workers' compensation or welfare pension plans. In dealing with insurance plans exempt under ERISA, the MIA requires plans to complete an "underwriter certificate", attesting to their status, rather than simply rely on the verbal assurance of the plan that it is self-funded.
The HEAU will contact plans which are exempt under ERISA to help resolve consumer complaints. Most of these plans are willing to discuss issues with the HEAU, but sometimes take the opportunity to remind the HEAU that they are under no obligation to do so.
B. Jurisdiction and Liaison with Health Plans
The MIA operates under two sets of legislation, one applying to the whole insurance industry and the other applying specifically to HMOs. These laws have different penalties, although there are moves under way to make the laws, including the penalties, more similar.
The MIA is currently responsible for licensing all health insurance plans including HMOs. As part of this process, and under the new Appeals and Grievances Law, HMOs are required to file details of their internal complaints processes with the MIA. This would generally occur at the initial issue of a license, but occurred for all existing HMOs when the legislation took effect on 1 January 1999.
In the 1960s when consumer protection laws were enacted, businesses that were otherwise regulated under existing legislation were exempted. This was the case with insurance plans which are therefore exempted from the operation of Maryland's consumer protection laws under the Office of the Attorney General.
Appeals and Grievances
The Maryland Insurance Administration's 1999 Report on the Health Care Appeals and Grievance Law provides a detailed analysis of the first 12 months of operation of the new legislation.
Under the new Appeals and Grievances Law, consumers who receive an adverse decision from their plan denying services based on lack of medical necessity have access to an internal grievance process through their health insurance plan. Similar to the Californian Department of Corporations, the MIA will not handle such complaints until the consumer has exhausted the plan's internal grievance process (unless there is an emergency or compelling reason). Health insurance plans generally have 30 days to respond to consumer grievances (1 day for emergencies, or 45 days for retrospective denials). However the HEAU will support and help consumers prepare their grievance during this period, and may also become involved in mediating disputes.
Within the MIA there are two separate units handling health insurance complaints. The Life & Health Complaints Unit handles all health insurance complaints that do not involve issues of medical necessity (e.g. coverage, premiums), while the Appeals & Grievances Unit handles grievances related to medical necessity. The Appeals & Grievances Unit in the MIA will become involved when consumers have exhausted the internal review process, at which time investigators will contact the plan, requesting a written response within seven days. The MIA may then refer the grievance for external review, using contracted Independent Review Organizations for medical review.
For general health insurance complaints MIA regulators noted that the vast majority of complaints are provider-driven, often arising from the Prompt Payment (30 days) requirement.
The Appeals and Grievances Law covers all health insurance plans (except those exempted under ERISA from state regulation, Medicaid and Medicare). Maryland did not attempt to define the appeals law as only applying to HMOs because of awareness that this would provide an incentive for new models of care to emerge which were not captured by a limited definition. The legislation deals with all commercial insurance plans including dental, catastrophic, medical and surgical etc.
When consumers are denied care, they must receive a letter including reference to the specific criteria on which the care is being denied. For example, payment for an emergency admission may require a patient to meet a specified number of criteria indicating their emergency status. Consumers often find out about the utilization review criteria used by the plan in denying care at the stage when they are required to seek pre-authorization. Sometimes this information can aid the health professional in more completely identifying patient characteristics and undertaking any other necessary tests to allow the patient to qualify for medical care.
Insurance plans are required to file their utilization review criteria with the MIA for approval. The MIA will examine the validity of these criteria, with the legislation requiring that these criteria are: objective, clinically valid, compatible with established principles of health care, and flexible enough to allow deviations from norms when justified on a case-by-case basis. Prior to the new legislation, the Department of Health and Mental Hygiene (DHMH) had responsibility for approving utilization review criteria of insurance plans. Staff at the HEAU commented that previous advice from DHMH staff was that plans that ran into difficulties in getting approval of their criteria tended to be those plans that developed criteria internally, rather than purchasing stock criteria. Now, the HEAU receives copies from the MIA of all plans' utilization review criteria which are often useful in the HEAU's informal assistance and mediation role during the internal grievance process.
HEAU staff noted that in order to keep denials out of the grievance process, insurance plans may attempt to find contractual reasons to deny care, rather than attributing it to the lack of medical necessity. For example, plans may attempt to deny jaw occlusions or plastic/reconstructive surgery on the grounds that these services are not covered. In recognition of this situation, the MIA's report on the operation of the Appeals and Grievance Law recommended that an appeal process also be established for coverage decisions. Legislation to expand the appeals and grievance process for coverage and contractual issues was passed by the Maryland General Assembly in 2000.
C. Complaints Reports and Data
Overview
The MIA does not publish regular reports directed specifically at consumers including comparative health insurance complaints data, similar to most of the other states in this study. In April 2000 the MIA issued a report focussing specifically on the operation of the new appeals and grievance law, but it has not published broader complaints data. In addition, the HEAU is required by law to issue an annual report on the Maryland appeals and grievance process, which includes a listing of the complaints filed against health plans.
In terms of plan-specific complaints information, the MIA noted that consumers were able to make formal Public Information requests but that consumers contacting the MIA with such a request tended to be referred on to the HEAU. HEAU staff noted that it received about 2-3 calls daily during the annual enrollment periods from consumers interested in the complaints history of specific plans. Staff have the ability to call up on screen aggregate data on complaints of individual insurance plans and can provide information to callers on the type of complaints received and how they were resolved. However staff of the HEAU are cautious in interpreting this information to consumers as "good" or "bad", as the database does not allow this material to be presented relative to the volume of business of the insurance company. The data include all complaints, with no attempt made to distinguish between "justified" and "not justified" complaints. The HEAU is installing a new complaints database which will assist staff in providing greater textual interpretation when they receive inquiries concerning complaints histories of individual insurance plans.
The MIA reports complaints data to the NAIC CDS for national tracking of complaints.
Two reports relevant to Maryland complaints management are available:
For each of reports, this study describes the major features, analyzes the data, and assesses the usefulness of the report from both the perspective of consumer friendliness and its value in monitoring the implementation of patient protection legislation.
D. Comparing the Quality of Maryland HMOs 1999 Consumer Guide
Features
The Maryland Health Care Commission (HCC), a public regulatory body established by the legislature, produces annual consumer report cards on HMO quality using HEDIS and CAPHS measures. The HCC produces three major types of reports:
The Consumer Guide released in June 2000, comprising results from 1999, includes two complaints measures using the CAPHS 2.0H Survey (included in HEDIS 1999). The survey, sent to 1,240 members of each plan, includes:
While Maryland was the first state to produce an HMO quality report card, this is the first time that complaint measures have been included in the annual consumer guide.
Findings
In 1999 26% of commercial HMO members reported that they called or wrote to their health plan with a complaint over the past 12 months, ranging from a low of 15% to a high of 35% across individual HMOs. (Note: the Policy Report indicates that the average complaint rate was unchanged from 26% in 1998.) When asked whether the complaint was resolved to their satisfaction, 56% said yes (range of 45-71%), 21% said no (range of 16-27%), and 23% said the complaint had not yet been settled (range of 12-31%).
Assessment of the Report
Consumer friendliness: The Maryland HCC report is presented in a manner which is simple and easy for consumers to follow. It uses a graphical presentation which compares the performance of individual HMOs, ranking them as average, higher than average or lower than average using colored circles. In addition, for consumers who want more detailed information, the report contains numerical scores with bar charts for all the performance measures for individual HMOs.
Monitoring patient protection implementation: As the complaints data does not provide any breakdown of the types of complaints experienced by patients, it is of limited use in tracking the implementation of patient protection legislation.
E. MIA Report on the Health Care Appeals & Grievance Law
Features
Scope - The report includes data from both the MIA and the HEAU on total health insurance complaints and grievances, covering between the first six to twelve months of operation of the new Appeals and Grievances Law. Complaints data in the report include a hierarchy of complaints management as follows:
Internal grievance data - the legislation requires that health insurance plans report to the MIA data on internal grievances including the outcome of grievances, with breakdowns by plans and by type of service.
Complaints received by the HEAU - this includes total complaints about all health services (e.g. providers, health insurance) and grievances whereby consumers (or providers) contact the HEAU once they have received a denial of care from their health insurance plan based on medical necessity.
Complaints received by the MIA - again, this includes data on total complaints and also grievances filed by consumers and providers. The MIA provides a breakdown of the grievance data by plan, outcome of the grievance and type of service.
Grievance categories - The MIA specifies the reporting format for health insurance plans to report on grievances (see page 33-35 of the MIA Report at Attachment 2). Plans must disaggregate grievances by type of service as follows:
In addition, for each of the service types, plans are required to report the five most common procedures/services/items that were at issue, using CPT codes or ICD-9 codes. The MIA requires that plans report on the number of grievances involving a hospital length of stay/denial of hospital stay, again including reference to the CPT or ICD-9 codes. Finally, the MIA requires that plans report on several process measures including: the outcome (original decision upheld, overturned or modified) and the average time for resolution of emergency and non-emergency grievances.
Findings
Consumers received a favorable decision in 60% of internal grievances made directly to health insurance plans, but the likelihood of a favorable decision varied significantly by the type of service.
Figure 4.1 shows the total number of grievances handled directly by health insurance plans in the first six months of 1999. Four service types - inpatient hospital services, emergency room access, pharmacy services and physicians - accounted for about three-quarters (72%) of all grievances. Figure 4.2 indicates the share of grievances decided in favor of the consumer. While 60% of all grievances resulted in the plan's initial decision being overturned or modified in favor of the consumer, this increased to 85% for grievances involving pharmacy services and 76% for laboratory radiology services services. Grievances which were the least likely to be overturned or modified in favor of the consumer were mental health services (28%), and podiatry/dental/optometry/chiropractic (38%).
Figure 4.1: Number of Grievances Handled by Health Insurance Plans, Maryland, January-June 1999
Figure 4.2: Outcome of Grievances Handled by Health Insurance Plans, Maryland, January-June 1999
The majority of complaints received by the MIA do not relate to grievances based on denial of care linked to medical necessity.
In 1999 the MIA Life & Health Complaints Unit received a total of 10,775 complaints, while the MIA Appeals & Grievances Complaints Unit received a total of 1,063 complaints.
The new Appeals & Grievances Law has more than doubled the number of complaints received by the Health Education and Advocacy Unit.
From 1996 to 1998 the HEAU received an average of 845 complaints annually, projected to grow to 2052 in 1999 (based upon the first six months of 1999). Prior to 1999 complaints about health insurance including HMOs comprised only 25% of the HEAU's workload, but this increased to more than 70% in 1999. Of complaints received by the HEAU in the first six months of 1999:
Assessment of the Report
Consumer friendliness - The MIA report is a policy analysis of the impact of the new Appeals & Grievances Law, rather than a report specifically targeted at consumers. For the complaints and grievances data in this report to be presented in a consumer-friendly way, one necessary change would be to compare individual plans on the basis of their market share, with complaints or grievances ratios calculated on the volume of premiums or insurance policies. MIA regulators commented that one issue in deConsumer friendliness - The MIA report is a policy analysis of the impact of the new Appeals & Grievances Law, rather than a report specifically targeted at consumers. For the complaints and grievances data in this report to be presented in a consumer-friendly way, one necessary change would be to compare individual plans on the basis of their market share, with complaints or grievances ratios calculated on the volume of premiums or insurance policies. MIA regulators commented tha
Monitoring patient protection implementation - The MIA reporting framework required for grievance reporting by health insurance plans is quite detailed by service type which would be useful for policy analysts in tracking certain patient protections (e.g. emergency room access). However the grievance reporting framework does not adequately capture "issues", as distinct from service types, including continuity of care and network adequacy. Ideally, data collected through the MIA (both the Health & Monitoring patient protection implementation - The MIA reporting framework required for grievance reporting by health insurance plans is quite det
F. Public Education Activities
Publications
The MIA has published a brochure titled "Need help with your HMO" which provides advice on the new Appeals & Grievances Law legislation and includes contact information for the MIA. The MIA website does not list any other health insurance publications.
The HEAU produces a range of brochures, guides and consumer tips including "When your health plan says 'no', "Making the most of your health insurance" and "Sorting out medical bills".
Outreach and Media
The Commissioner and senior MIA staff receive frequent inquiries for speaking engagements on complaints management, with a growing focus in the MIA towards consumer education. The Commissioner is very active in both the legislative and provider community, with press coverage resulting in growth in complaints. While the Annual Report of the MIA is tabled in the General Assembly, the Commissioner will publicize issues with complaints on an ongoing basis throughout the year, as they arise.
Staff of the HEAU undertake about 20-25 speeches to consumer groups annually and also staff information booths at fairs and other public events. However there is an information gap with consumer groups not particularly well focused and not actively using the HEAU office.
Following the passage of the appeals legislation, there has been quite strong demand from provider groups for HEAU staff to speak at public events. Mental health providers are the most well organized. Some other health professionals, including surgeons, have been much less active in using the legislation. Often it is the office practice managers who will be involved in handling patient complaints concerning insurance. However there are problems with poor communication between some professionals and their office practice managers. In one recent instance the State medical society sent information on the new appeals process to all its members. In a large radiology group practice comprising 95 radiologists, all the radiologists received this information but not one passed it on to the practice manager. The HEAU is now undertaking outreach activities to office practice managers, given their central role in patient complaints.
G. Agency Performance Issues
Staffing
The MIA has investigators who are specialized within two insurance lines, life and health or property and casualty. Life and health includes long term care, medical and surgical, life insurance and disability. The Life & Health Complaints Unit includes 1 Chief Investigator, one Quality Assurance Coordinator, nine investigators, one part-time investigator and three clerical staff to investigate and process non-medical necessity life, health and HMO complaints. Following the passage of the Appeals and Grievance legislation, the MIA established a new Appeals & Grievances Complaints Unit in the Consumer Complaint and Investigation Section with staffing as follows: 1 Chief Investigator, 5 Investigators, 2 clerical staff and 1 contractual physician.
The HEAU currently has 5 staff, 4 of whom personally handle grievances full-time. There are also 15-20 volunteers who handle most of the other complaints (i.e. non-grievances, complaints on billing issues etc).
Financial Savings to Consumers
The MIA collects some data on financial savings but noted that this is difficult to collect uniformly.
The HEAU captures some data on financial savings to consumers as a result of successful complaints resolution. In 1998 there were about $0.5 million of savings, while in 1999 the full- year savings are estimated to be between $1-1.5 million. However it is not always possible to fully capture this information or do so in a way that is comparable. The new database will allow the capture of two new fields - firstly, the $ that consumers want to get through complaints resolution, and secondly, the $ received as a result of action by the HEAU. It should be noted, however, that consumers are often very uncertain about what they want to achieve in resolving their complaint.
Consumer Satisfaction Surveys
The MIA does not undertake consumer satisfaction surveys for insurance complaints generally. Regulators commented that, given current staffing levels, they would prefer to have staff dealing directly with patient complaints rather than undertaking surveys.
However, following the passage of the Appeals & Grievance legislation, the MIA undertook a small mail survey in December 1999 of 342 individuals who had filed complaints with the Appeals & Grievances Complaints Unit. With a response rate of only 25%, the survey found that the majority of consumers were satisfied with their contacts with both the MIA and the HEAU. Appendix H of the MIA's Report (Attachment 2) includes the survey questions and analysis.
The HEAU undertook a consumer satisfaction survey in the past, using a brief 4-question survey which was hand tabulated. Staff noted that this was a fairly basic exercise and there was limited confidence in the validity of this exercise. Under the appeals legislation, the HEAU intends to survey providers and patients in 2000 regarding the operation of the new grievance process.
Audit
The MIA undertakes internal audit processes every 6 months and uses supervisory review in managing complaints. Regulators noted that this process will need to be reviewed and updated given the grievance and appeals legislation.
There has been no audit of the HEAU's operations. HEAU staff noted that the major concern of the General Assembly was timeliness by insurance plans in managing grievances, resulting in the requirement on insurance plans to respond to the MIA or HEAU in seven days on appeals.
Timeliness of Complaints Resolution
While the HEAU does track time taken to resolve complaints, this data is currently not particularly reliable. It is a low priority of staff to record when complaints are closed, so that this information will often overstate the time taken for closure. However the HEAU does run reports from its database, checking the length of time taken.
A further issue in monitoring time for resolution of complaints is that the largest delay under the new grievance process is getting authorization from the patient and/or getting necessary information from the clinical provider. The legislation requires insurance plans to respond within seven days, but imposes no timelines on other parties to the complaint. One of the major health providers in Maryland is attempting to get patient consent to the grievance process included on their admission/treatment forms which would expedite the process if it needs to be invoked.