Patients in Conflict with Managed Care

A Profile of Appeals in Two HMOs: Contrary to Popular Belief, Most Appeals Are Not About Insurers' Denials of Coverage for Potentially Life-Saving Care

Published in: Health Affairs, v. 21, no. 4, July/Aug. 2002, p. 189-196

Posted on on December 31, 2001

by Carole Roan Gresenz, David M. Studdert, Nancy F. Campbell, Deborah R. Hensler

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Despite speculation about the nature of disputes between managed care enrollees and their health plans over benefit denials, little empirical information exists about the details of such disputes and how they are actually handled. In this study the authors profile more than 11,000 appeals lodged between 1998 and 2000 by enrollees at two of the nation's largest health maintenance organizations (HMOs), to shed some preliminary light on the vast terrain of enrollee appeals. As many as half of appeals involved requests for reimbursement for costs of services already obtained (retrospective appeals), as opposed to services sought (prospective appeals). Enrollees won 36 percent of prospective appeals at Plan 1 and 70 percent at Plan 2, compared with 89 percent and 78 percent, respectively, of retrospective appeals. The success rate among retrospective appeals involving emergency room services--95 percent at both plans--was particularly striking.

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