Cover: Patient-Reported Denials, Appeals, and Complaints

Patient-Reported Denials, Appeals, and Complaints

Associations With Overall Plan Ratings

Published in: The American Journal of Managed Care, Volume 24, Issue 3, pages e86-e92 (March 2018)

Posted on rand.org Jun 27, 2024

by Denise D. Quigley, Amelia Haviland, Jacob W. Dembosky, David J. Klein, Marc N. Elliott

Objectives

To assess whether Medicare patients' reports of denied care, appeals/complaints, and satisfactory resolution were associated with ratings of their health plan or care.

Study Design

Retrospective analysis of 2010 Medicare Advantage Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data.

Methods

Multivariate linear regression of data from 154,766 respondents (61.1% response rate) tested the association of beneficiary ratings of plan and care with beneficiary reports of denied care, appeals, complaints, and complaint resolution, adjusting for beneficiary demographics.

Results

Beneficiaries who reported being denied needed care rated their plans and care significantly less positively, by 17.2 points (on a 100-point scale) and 9.1 points, respectively. Filing an appeal was not statistically significantly associated with further lower ratings. Beneficiaries who filed a complaint that was satisfactorily resolved gave slightly lower ratings of plans (-3.4 points) and care (-2.5 points) than those not filing a complaint (P <.001 for all results).

Conclusions

Lower ratings from patients reporting complaints and denied care may notably affect the overall 0-10 CAHPS ratings of Medicare Advantage plans. Our results suggest that beneficiaries may attribute the actions that lead to complaints or denials to plans more than to the care they received. Successful complaint resolution and utilization management review might eliminate most deficits associated with complaints and denied care, consistent with the service recovery paradox. High rates of complaints and denied care might identify areas that need improved utilization management review, customer service, and quality improvement. Among those reporting being denied care, filing an appeal was not associated with lower patient ratings of plan or care.

Research conducted by

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