From 1998 to 2000, staff at the American Bar Association Commission on Legal Problems of the Elderly surveyed managed care plans on their current practices for resolving enrollee-plan disputes. The project emphasized disputes involving older people and recommended workable options for improving dispute resolution.
Findings from a published report, Understanding Health Plan Dispute Resolution Practices, include:
- Many health plans have developed fair and effective practices in customer service, grievances and appeals.
- Compliance with multiple regulatory requirements is the primary challenge health plans face in implementing dispute resolution systems.
- The most common appeals, in order of frequency, are for:
- Emergency room coverage.
- Pharmacy issues.
- Coverage for referrals that have not been authorized.
- Out-of-network coverage.
- Contractual interpretation of benefit coverage.
- Benefits excluded by contract but needed by the member.
- Billing problems.
- Coverage for durable medical equipment.
- There is no uniform set of guidelines or agreed-upon standards for making "medical necessity" determinations.
- Plans do not consistently give timely written notice of their initial decision to deny services or payment, or their decision to reduce or terminate services.
- When members appeal, health plans overturn their initial decisions in a substantial number of cases.
- Many Medicare enrollees have difficulty understanding and participating in the appeals process.