Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. 3. Complaints Analysis and Agency Performance Issues


Internal use by agency:

  • Do you routinely provide access to complaints data to other sections of your agency? (for example, agent licensing, market conduct, rates and forms, legal, financial examination section) In particular, do you provide aggregate data to any of these sections, rather than simply seeking their involvement in resolution of individual complaints? Please describe what information you share and how this is used.
  • Do you follow up unusual levels or patterns of complaints against specific plans?

Comparative complaints information:

  • Do you publish complaints ratios ranking the performance of health insurance plans/HMOs on the basis of the volume of complaints? (seek report/citation)
  • Does this material include the raw number of complaints against each plan?
  • Are complaints ratios published which adjust for volume of business and, if so, how? (e.g. premiums written, number of policies, other measure)?
  • When did you commence publication of this material and how frequently is it published?
  • Does your publication include annual trends or is it point in time?
  • What is the basis of complaints included in these reports? (e.g. all complaints, justified complaints, closed complaints etc - obtain relevant definitions)
  • Are complaints only included above a certain minimum number or a certain level of business in the state? What is the proportion of total complaints received by your office included in these reports?
  • Does this material distinguish types of complaints and if so, what are the groups used? (e.g. rating, policy, marketing/sales, claims handling, other)
  • Who is eligible to make complaints - consumers, providers, others? Do you impose filing time limits beyond which you will not accept complaints?
  • What is the consumer feedback on this report - ease of understanding? usefulness? How do you handle consumer perceptions of "poor performance" when there is an increase in complaints?
  • In investigating complaints, what is the extent of the information provided back to consumers? Do you provide all information sent to you by the health plan or HMO or will you provide a summarized version to the consumer? To what extent is any of the information protected?

Analysis of complaints data:

  • What analyses of complaints data do you undertake? What standard reports do you generate from your complaints database and who has access to these reports? (seek copies)
  • What have been the trends in total complaints over time and what factors do you believe are contributing to the change? (Seek quantitative information)
  • How do you categorize complaints (including types of coverage, reasons for complaints, disposition of complaints)? (Seek documentation of how complaints are categorized).
  • Do you use the same categories used by the NAIC for the CDS (Complaints Database System)? Do you submit complaints data to the NAIC? If not, why not?
  • Has there been a change in the type of complaints (e.g. rating vs policy service) and what factors have contributed to any such change?
  • To what extent does your database allow you to track complaints as new issues emerge (e.g. privacy of genetic information, denial of care for managed care plans)? Have you made any recent changes to how you record the types of complaints in response to new issues?
  • Do you analyze complaints data to assess the effectiveness of legislative, rule or policy changes instituted by the state government or your agency? For example, to what extent have you tracked changes in complaints relating to rating before and after rating reforms?

Agency performance issues:

  • What resources (staffing) are currently available to manage the complaints function in your agency? How has that changed over time and is it adequate to meet the demand?
  • Do complaints staff in (name of state agency) work across all lines of insurance or do they specialize in one area? What are the advantages and disadvantages of these approaches?
  • What additional data do you have on the performance of your agency in managing complaints including:
  • Number of unanswered calls?
  • Average time taken to achieve resolution of complaints?
  • Volume of complaints handled (if not answered in complaints analysis section)?
  • Number of hits on your website, including number of hits on electronic complaints form, complaints brochures or complaints reports?
  • Accuracy of information provided?
  • To what extent does your agency track financial savings to consumers resulting from successful complaints resolution? How is this data collected (e.g. consumer reporting on $ saved, application of standard formulae)? (seek copies of information on financial benefits of complaints management process)
  • Has there been any independent evaluation or auditing of your complaints management processes (e.g by another state government agency) and, if so, what if any changes were recommended to improve the complaints function? What aspects of your agency's function were audited - timeliness, compliance with legislative framework, other?
  • Do you undertake consumer satisfaction surveys of the complaints function? If so, how frequently and how many consumers are sampled? What have been the results of these surveys?
  • If consumers are not satisfied with the outcome of your agency's decision, what channels are open to them to have the decision reviewed?