DMHC Handled More Consumer Complaints and in More Timely Manner Last Year, Report Indicates
The Department of Managed Health Care resolved a "record number" of complaints from HMO consumers last year, at a quicker pace than ever before, according to a new report from the department. The report, "John Q. Doesn't Live Here Anymore," found that the DMHC's HMO Help Center received and resolved 171,182 consumer complaints in 2001, covering issues from "paperwork hassles" to "complicated medical disputes." In all, 36% of complaints reflected issues of denial of care or payment for care; 22% involved coverage or benefit disputes; 16% were related to quality of care issues; 16% were over billing or financial issues; and 4% reflected "attitude" or service issues. The Help Center also demonstrated a significant improvement in the time it takes to address complaints. When the center was launched on July 1, 2000, the state had a backlog of complaints, nearly 60% of which were more than 30 days old. By early 2001, that number had been reduced to 5%, according to the report (Office of the Governor release, 10/3).
An independent panel of physicians reviewing complaints about coverage denials filed with the Help Center last year found that HMOs incorrectly determined a treatment was medically unnecessary in "hundreds of cases," the report also found. The San Francisco Chronicle reports that of the 171,182 calls the Help Center received last year, more than 700 were sent to a panel of independent physicians for further review. In almost 50% of the cases in which an HMO ruled a treatment was medically unnecessary, the panel overruled the decision, the report indicates. Further, the panel disagreed with an HMO ruling in 20% of the cases in which the HMO declared a treatment "experimental." DMHC Director Daniel Zingale said the findings are likely "the tip of the iceberg" because "only a fraction" of Californians covered by HMOs are aware of the services provided by the DMHC and its Help Center. California Association of Health Plans President Walter Zelman said the statistics indicate that the HMOs "usually make the right decisions," the Chronicle reports. He added, "There are always going to be gray area cases. That is why this process is there" (Wallack, San Francisco Chronicle, 10/3).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.