Researchers Find Elderly Patients Need Help in Navigating Disputes Over Care

    • November 1, 2001

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.

Key Findings

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.