Merritt Personal Lines Manual: Grievances, Complaints, Appeals, etc.

MedicareAdvantage guidelines spell out detailed time limits for health plans to respond and resolve grievances and appeals filed by or on behalf of enrollees. There are also provisions for enrollees to access independent entities to represent their interests in disputes with Medicare plans.

• Grievances cover comparatively minor issues. An example of a grievance would be an enrollee's complaint to the health plan about the demeanor of a medical provider or office staff or the physical condition of the office.
• Organization determinations involve whether an enrollee is enrolled to receive a health service, the amount the enrollee is expected to pay for that service or the medical necessity of the service or its setting.
• Reconsiderations deal with review of adverse organization determinations. Standard reconsiderations may be filed with the Medicare managed care plan or a Social Security agency office.

Enrollees have the right to appeal disagreeable organization determinations. Provisions exist for several levels of appeal. In the language of the interim final rules, appeal means any of the procedures that deal with the review of adverse organization determinations. The first level is a simple reconsideration by a group internal to the health plan. If enrollee satisfaction is not achieved at this level, the next step would be to have a hearing before administrative law judges (ALJs), then reviews by the Departmental Appeals Board. The final step would be instituting judicial review.

Enrollees are to receive complete, as well as timely, appeal decision disclosure. If a Medicare managed care organization decides to deny any service or payment, it must provide written notice of the determination. It must:

• state the specific reasons for the denial in understandable language;
• inform the enrollee of his or her right to a reconsideration; and
• describe the standard in expedited reconsideration processes.

Only enrollees have the right to a hearing before an ALJ - the Medicare managed care organization does not have the right. The final step in the appeals process is a Departmental Appeals Board, where an enrollee dissatisfied with the ALJ hearing decision may request review.

An enrollee or physician may request an expedited organization determination for services. The request may be oral or written. The Medicare managed care organization must document all oral requests and maintain documentation. If the Medicare managed care organization denies a request for expedited determination, it must automatically transfer the request to the standard 14-day time frame and make determination within that period.

The Medicare managed care organization must also give the enrollee prompt oral notice of the denial and follow up within two working days with a written letter that outlines the terms of the grievance process.

One of the greatest fears of many Medicare managed care enrollees is denial of further inpatient hospital treatment once they've been admitted to a hospital. This problem comes to a point when an attending physician and the health plan disagree about the need for further inpatient care. Should you follow your doctor's advice and run the risk of denied claims and devastating out-of-pocket costs? Or should you ignore the doctor - and risk possible medical complications?

There is a quick solution. You have the right to request immediate review of noncoverage of inpatient hospital care by an independent professional standards review (PRO) organization. An enrollee who requests immediate PRO review may remain in the hospital with no additional financial liability. An enrollee who fails to request immediate PRO review and instead relies on the Medicare managed care plan's expedited reconsideration is liable for payment of nonmedically necessary days.

The PRO must notify the Medicare managed care plan on the day it receives the request. The plan must supply information needed by the PRO to process the review. The hospital must submit medical records or other pertinent information to the PRO by the close of business on the first full working day.

The PRO then makes a determination and notifies you, the hospital and the plan by the close of business on the first working day after it receives all necessary information from the hospital and the Medicare Advantage organization.