Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. C. Complaints Reports and Data


Neither the DHCA nor the Ombudsman Office publish complaints "report cards", comparing the complaints performance of individual plans.


The DHCA has recently published the report "Vermont Managed Health Plans: A Guide for Consumers 1999" (Attachment 3). This health quality report card covers the performance of the four managed care plans against five categories of indicators: getting care, customer service; claims handling; women's health care; and care for children, with the first three categories collected through a CAPHS survey and the last two categories collected from plan records according to HEDIS. The guide is very consumer friendly and uses colored circles to classify plans as providing average, higher than average or lower than average care.

However unlike four of the six states studied in this report, Vermont does not currently report complaints data publicly. The guide does explain that all managed care plans are required to have an appeal process that allows consumers to complain about decisions and it includes the toll free number of the Consumer Services Section of the Division of Health Care Administration. It also refers to the Office of the Health Care Ombudsman and notes that the Ombudsman is a non-profit organization established to help Vermonters with questions and concerns about all kinds of health insurance.

In 1998 the DHCA received 4501 phone inquiries and processed 290 formal complaints. Regulators noted that the breakdown of inquiries matches the split of indemnity (80%) and managed care (20%) in the Vermont health insurance market. In 1997/98 of the 290 formal complaints, 67 (23%) were about managed care and 223 about non-managed care (77%). In 1999 the most common complaints have been about mental health parity, consumer rights and chiropractic care.

Attachment 4 is the Telephone Call Intake Form used by the DHCA Consumer Services Specialist in handling calls (both inquiries and complaints) to the Hotline. The issues categories used by the DHCA are quite comprehensive and would provide a sound basis for monitoring the implementation of managed care patient protections. In particular, the access issue categories cover problems such as clinical denial of care, specialty care, and emergency care.

The DHCA enters the information captured on the telephone call intake form into a new database, the purpose of which is to track calls, keep record of which is being mailed out for publications, provide information for reports to the legislature, and track trends.

Unlike some other states, the DHCA does not distinguish between all complaints and justified complaints. Regulators commented that DHCA's role was as a mediator and facilitator, helping both sides work through the process, not to sit in judgement as to the validity of the call.

If a consumer rings the DHCA requesting company-specific complaints information, the Consumer Services Specialist can retrieve this information from the database and advise of the number of complaints in the last year. The database does not automatically generate complaint indices for individual plans or industry averages. However, in conversation with consumers, the Consumer Services Specialist will attempt to put the complaints history of a plan in perspective, by advising them about the size of the plan as measured by covered lives.

Complaints received by the DHCA are reported into the NAIC CDS.

The DHCA does not provide regular reports to other parts of BISHCA, but will informally send information as needed. Regulators commented that complaints management and tracking is the primary function.


In 1999 the Ombudsman Office received 1,775 phone calls. Attachment 5 is the data collection form used by the Office, which is broadly similar to that used by the DHCA. Again, the issues classification has the potential to identify the impact of various managed care legislation protections.

Currently access to dental services and prescription medicines are among the most common advocacy complaints. The Vermont legislature is considering a bill to regulate the cost of prescription drugs. The Office receives relatively few calls regarding access to primary care physicians. While Rule 10 contains access standards, a consumer may ring the Office because he/she is experiencing difficulty accessing a primary care physician. In this situation the Ombudsman Office may take immediate action to help the consumer find a physician and then also refer on the broader issue about the network adequacy of individual plans to the DHCA. There are similar issues involving continuity of care where the Ombudsman Office helps resolve the immediate problem and then contacts the DHCA about the systemic issue.

Consumers do not tend to ring the Ombudsman Office asking for the complaints history of individual plans. Consumers do call seeking advice as to the "best plan". The Ombudsman Office mainly helps them by identifying their needs (e.g. prescription drug coverage) and working through with them available information on plans (e.g. using DHCA information on managed care plans, premiums and benefit packages).

The Ombudsman Office accepts calls from both consumers and providers. Providers may call about particular patient issues or systemic issues (e.g. the level of Medicaid reimbursement, or delays in payment by insurance plans). While the Ombudsman Office encourages providers to use provider organizations, it may use the systemic problems identified in advocacy efforts.

In terms of feedback to consumers on complaints, the Ombudsman Office provides essentially all the information they uncover back to the consumer, including the process they undertook and what they found.

The Ombudsman tries to balance two roles - helping individual consumers and systemic advocacy issues. The Ombudsman has regular meetings with the Office of Vermont Health Access and the DHCA raising systemic advocacy issues. The Ombudsman also participates in the Vermont Health Access Oversight Committee (the Medicaid waiver committee), which is a legislative committee, and a very good vehicle for systemic advocacy.

In addition to an annual report to the legislature, the Ombudsman program makes quarterly reports to the DHCA and the Vermont Office of Health Care Access including the total number of calls, the types of calls and a narrative which highlights the policy issues involved.