oversight

Medicare Managed Care: Greater Oversight Needed to Protect Beneficiary Rights

Published by the Government Accountability Office on 1999-04-12.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to the Special Committee on
                 Aging, U.S. Senate, and the Honorable
                 Jack Reed


April 1999
                 MEDICARE
                 MANAGED CARE
                 Greater Oversight
                 Needed to Protect
                 Beneficiary Rights




GAO/HEHS-99-68
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      Health, Education, and
      Human Services Division

      B-281220

      April 12, 1999

      The Honorable Charles E. Grassley
      Chairman
      The Honorable John Breaux
      Ranking Minority Member
      Special Committee on Aging
      United States Senate

      The Honorable Jack Reed
      United States Senate

      Since 1994, enrollment of Medicare beneficiaries in managed care has
      tripled to 7 million—comprising 18 percent of all Medicare beneficiaries.
      Beneficiaries who enroll in managed care are entitled to all
      Medicare-covered services. They also may benefit from lower
      out-of-pocket costs, additional covered benefits, and less paperwork than
      their counterparts in traditional fee-for-service Medicare. Unlike
      fee-for-service providers, however, managed care plans receive a fixed
      amount per month for each enrolled beneficiary, regardless of the type
      and number of services they provide. Consequently, plans have a financial
      incentive to limit beneficiaries’ use of health care services. To safeguard
      access to appropriate covered services, Medicare allows beneficiaries to
      appeal—first to their managed care plans and then externally—whenever
      their health plans deny requested care or refuse to pay for services.1

      Because the appeals process helps safeguard Medicare beneficiaries’ right
      to covered services from managed care plans, you asked us to assess the
      adequacy of the process, including the recently instituted expedited
      process. Specifically, you asked us to focus on the appeals process at the
      plan level, providing information on (1) the appeals process available to
      beneficiaries when managed care plans deny care or payment for services,
      (2) beneficiaries’ use of the appeals process and the extent to which they
      are informed of their appeal rights, and (3) the Health Care Financing
      Administration’s (HCFA) oversight of this process.

      To conduct our review, we interviewed officials from HCFA; the Center for
      Health Dispute Resolution (CHDR), HCFA’s contractor that reviews plans’
      appeal decisions; and selected managed care plans. We also reviewed
      HCFA’s 1997 managed care plan monitoring reports and reports by the


      1
       Similarly, beneficiaries in fee-for-service Medicare who disagree with a decision on the amount
      Medicare will pay on a claim or whether services received are covered by Medicare may appeal the
      decision.



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                   Office of Inspector General (OIG) in the Department of Health and Human
                   Services (HHS), analyzed the results of a questionnaire sent to all health
                   maintenance organizations (HMO) about their plan-level appeals, reviewed
                   a number of appeals forwarded to CHDR, and collected statistical data from
                   HCFA and CHDR on plan appeals. In addition, we accompanied agency staff
                   on two monitoring visits to plans and visited four HMOs. We performed our
                   work between June 1998 and April 1999 in accordance with generally
                   accepted government auditing standards. (See app. I for details on our
                   scope and methodology.)


                   Medicare beneficiaries enrolled in managed care plans have the right to
Results in Brief   appeal if their plans refuse to provide health services or pay for services
                   already obtained. For example, if a plan denies a beneficiary’s request for
                   skilled nursing care or a referral to a specialist, it must issue a written
                   notice that explains the reason for the denial and the beneficiary’s appeal
                   rights. Upon receipt of the written denial notice, the beneficiary may
                   appeal and the health plan must reconsider its initial decision. If the plan’s
                   reconsidered decision is not fully favorable to the beneficiary, the case is
                   automatically sent to CHDR to review the decision. CHDR may overturn or
                   uphold the plan’s decision. A beneficiary is entitled to an expedited
                   decision from the plan, both on the initial request and on appeal, if the
                   standard time for making the decision could endanger his or her health or
                   life. A beneficiary who is dissatisfied with CHDR’s decision may appeal
                   further to an administrative law judge (ALJ) and then to a U.S. District
                   Court, provided certain requirements are met.

                   HMOs   reported an average of approximately 9 appeals per 1,000 Medicare
                   members annually between January 1996 and May 1998. HMOs reversed
                   their original denial in about 75 percent of appeal cases. The number of
                   appeals, however, may understate beneficiaries’ dissatisfaction with the
                   initial decisions by HMOs for two reasons. First, some beneficiaries may
                   disenroll and switch to another plan or fee-for-service Medicare instead of
                   appealing. Second, some beneficiaries may not appeal because they are
                   unfamiliar with their appeal rights or the appeals process. We found that
                   beneficiaries frequently received incomplete notices that failed to explain
                   their appeal rights; some beneficiaries did not receive any notices. In
                   addition, notices often do not state a specific reason for the denial; as a
                   result, beneficiaries may be uncertain as to whether they are entitled to
                   the requested services and thus be discouraged from appealing. We also
                   found that beneficiaries may receive little advance notice when plans
                   decide to discontinue paying for services, such as skilled nursing care,



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             which places these beneficiaries at financial risk should they decide to
             continue treatment during their appeal. In general, beneficiaries who lose
             their appeals are responsible for the treatment costs incurred after the
             date specified in the denial notice.

             HCFA’s  oversight of health plans’ appeals process has several shortcomings.
             The agency does not determine whether beneficiaries who were denied
             services but did not appeal were informed of their appeal rights. It also
             does not monitor provider groups that contract with health plans. Many of
             these groups play a key role in the appeals process by issuing denial
             notices and deciding whether to expedite initial decisions. HCFA has not
             ensured consistent implementation of the expedited appeals process
             because it has not issued specific criteria for expedited cases. We found
             that a group of health plans in one HCFA region had collaborated to develop
             such criteria. The HCFA regional office subsequently issued these criteria to
             plans in its region. Finally, HCFA has not used available information to
             develop more effective plan oversight strategies. The agency is planning to
             gather plan-level appeals data (similar to the data we collected for this
             report), but actual data collection may not begin for another year. In
             commenting on a draft of this report, HCFA agreed that the agency needs to
             improve its oversight of the appeals process. HCFA cited several initiatives
             it is currently undertaking to better protect beneficiaries’ rights.


             In 1998, about 7 million—or 18 percent—of Medicare’s 39 million
Background   beneficiaries were enrolled in a managed care plan. About 90 percent of
             Medicare managed care enrollees belong to one of 307 risk-contract HMOs.2
             These plans are paid a predetermined monthly amount for each Medicare
             enrollee, regardless of the amount of Medicare covered services the
             enrollee uses. The plans are called “risk” HMOs because they assume the
             financial risk of providing care for the amount Medicare pays.

             Risk HMOs must provide all services covered by fee-for-service Medicare; in
             many instances, they provide additional services—such as outpatient
             prescription drugs and routine physical exams. Generally, plans require
             enrollees to use only providers that contract with the plan and to follow
             certain procedures to obtain health care services. For example, most plans
             require enrollees to obtain prior authorization for care either from their
             primary care physician or directly from the plan. If enrollees do not follow
             the procedures, plans may not pay for the services.

             2
              There are also cost-contract plans, where Medicare pays the actual cost the entity incurs in furnishing
             covered services less the estimated value of beneficiary cost-sharing, and health care prepayment
             plans, which are similar to cost-contract plans except that they provide only Medicare part B services.



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HCFA Performs On-Site       HCFA performs biennial on-site performance reviews of each health plan’s
Monitoring of Plans Every   operations, including the appeals process, to evaluate plan compliance
2 Years                     with HCFA regulations. HCFA staff review a sample of appeal cases and
                            evaluate whether the plan met Medicare process and timeliness
                            requirements. Results of the performance review are reported in the
                            monitoring report. The report documents whether a plan met all legal and
                            policy requirements and describes any deficiencies and needed corrective
                            actions.


Class Action Lawsuit        In November 1993, a class action lawsuit filed against the Secretary of HHS
Challenges Medicare         challenged a number of the policies and practices of the Medicare
HMOs Appeal Practice        managed care program. As a result of this lawsuit, HCFA is currently under
                            an injunction and order issued by the federal district court that requires
                            Medicare HMOs to give their enrollees written notices that meet certain
                            criteria.3 Specifically, the order required, among other things, that
                            Medicare HMOs (1) issue denial notices within no more than 5 working
                            days of the request for service or payment and at least 1 working day
                            before the reduction or termination of treatment, (2) clearly state the
                            reason for the denial in the notice, (3) expedite appeals when services are
                            urgently needed (within 3 working days of the request), and (4) continue
                            acute care services until a final appeal decision is issued when the
                            beneficiary requests an expedited appeal.4

                            Since the 1997 court order, HCFA has required each plan to implement an
                            expedited process for decisions on initial requests for health services and
                            appeals of denied health services. Subsequently, the expedited process
                            was mandated along with other appeals procedures and beneficiary
                            protections by the Balanced Budget Act of 1997 (BBA) and further
                            addressed in the Medicare+Choice regulations published in June 1998. A
                            beneficiary may now request an expedited decision if he or she believes
                            that serious adverse health consequences could result from waiting for a
                            decision under the standard process.




                            3
                              Grijalva v. Shalala, 946 F. Supp. 747 (D. Ariz. 1996), Oct. 17, 1996; subsequent judgment implementing
                            the order was issued Mar. 3, 1997.
                            4
                             HCFA appealed the decision of the lower court to the U.S. Court of Appeals for the 9th Circuit, which
                            on August 12, 1998, upheld the lower court’s decision. HCFA’s second appeal was also denied. On
                            February 10, 1999, HCFA asked the U.S. Supreme Court to review the case.



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                             Medicare beneficiaries enrolled in managed care plans have a multilevel
Medicare                     appeals process available if plans refuse to pay for requested services,
Beneficiaries Can            refuse to provide requested services, or discontinue or reduce services.5
Appeal Plan Decisions        Beneficiaries generally appeal to their plan first.6 If the plan upholds the
                             initial denial, the appeal is forwarded to CHDR for external review and
                             resolution.7 However, a further appeal to an ALJ and the court is possible.
                             Under certain circumstances, a beneficiary or a health care provider may
                             request that a plan expedite its decision on the initial request and any
                             subsequent appeal.


Appeals Process Starts at    The appeals process may begin when a Medicare member asks his or her
Managed Care Plan but Is     plan to provide a service, such as skilled nursing care or a referral to a
Subject to External Review   specialist, or pay for a service already obtained and is turned down.8 In
                             such instances, Medicare requires plans to issue a written notice that
                             states the reason for the denial and explains the beneficiary’s appeal
                             rights. A member has 60 days from the date of the denial notice to ask the
                             plan to reconsider its initial decision.9 The appeal request, which must be
                             in writing, can be addressed to the member’s health plan or the Social
                             Security Administration, which will forward it to the health plan. A
                             member is not required to submit additional information to support or
                             clarify the request. However, health plans must provide their members the
                             opportunity to supply such information.

                             The plan’s reconsideration of its initial decision, the internal portion of the
                             appeals process, must conform to certain requirements. Prior to July 27,
                             1998,10 a plan had up to 60 days to complete this process; now a plan must
                             reconsider its initial decision within 30 calendar days if the request is for

                             5
                              Health plans must also have a process for handling beneficiary complaints about quality of services,
                             timeliness of services, and administrative problems. Such complaints, known as grievances, may not
                             be appealed outside the plan. In commenting on a draft of this report, HCFA said that it is developing
                             an additional set of requirements for grievance processes.
                             6
                              Beneficiaries discharged from a hospital by their HMO may appeal to peer review
                             organizations—organizations that include practicing doctors and other health care professionals,
                             under contract to the federal government to monitor the care given to Medicare patients.
                             7
                              CHDR reviews plans’ appeal decisions that are not wholly favorable to the enrollee. An independent
                             review of a plan’s adverse initial decision is required by 42 C.F.R. 417.614.
                             8
                              All parties to the initial decision have a right to appeal. This includes the member, a representative of
                             the member, a legal representative on behalf of a deceased member’s estate, and any other entity
                             determined to have an appealable interest in the proceeding, such as out-of-plan physicians or
                             suppliers.
                             9
                              A member may appeal a denied service or payment for service even if a notice is not issued.
                             10
                                 This was the effective date for Medicare+Choice regulations, issued on June 26, 1998.



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health care services and within 60 calendar days if it is for payment.11 The
plan representative considering the appeal must not have been involved in
making the initial decision. To make a reconsidered decision, the plan
representative reviews the initial decision and all other evidence
submitted by the beneficiary, beneficiary representative, provider, and
health plan.

If a plan upholds, in whole or part, its initial denial, it must forward the
case to CHDR for external review.12 HCFA has modified its contract with
CHDR requiring CHDR to be held to the same time standards as the plans for
processing appeals. (Prior to the change, CHDR had 30 days to consider the
case, make its ruling, and inform the beneficiary of its decision.) If CHDR
upholds the plan’s denial, the beneficiary can request an additional appeal
before an ALJ, provided the services in question cost at least $100.13 A
beneficiary may ask that the Social Security Departmental Review Board
review a denied ALJ appeal. If the board declines to review the ALJ decision
or denies the appeal and the amount of the services in question is greater
than $1,000, the beneficiary may request a hearing in U.S. District Court. A
beneficiary who loses an appeal is responsible for the cost of any disputed
health care services that he or she obtained. Figure 1 shows the Medicare
appeals process, step by step.




11
 HCFA also established new processing time frames for initial determinations. Plans must make these
decisions within 14 calendar days for request of health services and 30 calendar days for payment of
services. The time frames can be extended up to an additional 14 calendar days, if such extension
would be helpful to the beneficiary.
12
  For calendar years 1996 and 1997 and the first 7 months of 1998, CHDR received 5,543, 8,152, and
6,334 appeal cases, respectively.
13
 The beneficiary has 60 days from the date of HCFA’s reconsideration determination to request a
hearing before an ALJ.



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Figure 1: Medicare Appeals Process




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Beneficiaries or Their      Since August 28, 1997, HCFA has required managed care plans to establish
Physicians Can Request an   and maintain an expedited process covering both initial decisions and
Expedited Decision          internal appeals. Medicare beneficiaries can request expedited decisions
                            when they believe that waiting the standard time for an initial decision or
                            an appeal of the initial decision could seriously jeopardize their health or



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life. If a beneficiary makes the request, the plan determines whether the
expedited process is warranted. If a physician makes the request on behalf
of a beneficiary or concurs with the beneficiary’s request, the plan must
expedite its decision. Generally, health plans must make the expedited
decision within 72 hours following the request.14 An expedited decision
that is adverse to the beneficiary must be forwarded to CHDR within 24
hours.15 CHDR is required to process the expedited cases within 72 hours.16
Figure 2 provides the time intervals for major events in the process.




14
  Certain exceptions allowed plans an extension of up to 10 additional working days. This was
redefined to 14 calendar days, effective July 27, 1998.
15
  CHDR received 870 expedited appeal cases in 1997 and 1,755 expedited appeal cases during the first
7 months of 1998.
16
  Prior to August 1998, CHDR had up to 10 days to process expedited cases.
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Figure 2: Elapsed Time for Major
Events in the Appeals Process




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                                      HMOs  that responded to our survey reported receiving approximately 9
Beneficiaries’ Limited                appeals annually per 1,000 Medicare members.17 However, this number
Use of the Appeals                    may understate beneficiaries’ dissatisfaction with HMOs’ initial decisions.
Process May                           First, dissatisfied beneficiaries may disenroll and switch to another plan or
                                      fee-for-service instead of appealing. Second, beneficiaries may be
Understate                            unfamiliar with their appeal rights or the appeals process. Plans may not
Dissatisfaction With                  always issue the required notices or may omit an explanation of
                                      beneficiaries’ appeal rights. In other cases, beneficiaries may not appeal
HMOs’ Initial                         because the notices list nonspecific reasons for the denial.
Decisions
Annual Appeals Per 1,000              The number of annual appeals per 1,000 Medicare beneficiaries varied
Beneficiaries Varied                  among HMOs and may be rising. The 242 Medicare HMOs that responded to
Among HMOs                            our recent survey reported an average of about 9 appeals annually per
                                      1,000 beneficiaries between January 1996 and May 1998 (see table 1).
                                      Generally, plans overturned nearly three-quarters of the requested appeals.
                                      Those not overturned were submitted to CHDR for further review and
                                      consideration. Between August 28, 1997, and December 31, 1997, plans
                                      expedited 861 appeals.18 During the first 5 months of 1998, plans expedited
                                      1,548 appeals.

Table 1: Medicare Risk HMO Internal
Appeals, 1996 to May 1998                                                                  Average                Annual number of
                                                                    Percentage of          monthly                appeals per 1,000
                                                      Number         all risk HMO        enrollment         Total         Medicare
                                      Year           of HMOsa            enrollees        (millions)      appeals         enrollees
                                      1996                  160                84                  2.7      22,437                      8.2
                                      1997                  223                85                  3.9      31,844                      8.1
                                      1998b                 242                89                  4.8      21,138                     10.5
                                      Note: Table reflects responses from 242 HMOs that completed GAO’s questionnaire on internal
                                      appeals.
                                      a
                                       Number of HMOs that responded to our survey in 1998 and were active in given year.
                                      b
                                          Includes first 5 months of 1998.

                                      Source: GAO survey of Medicare risk HMOs active as of May 31, 1998.



                                      17
                                        In July 1998, we surveyed all (307) HMOs with active Medicare enrollment as of May 31, 1998. Eighty
                                      percent of the HMOs, representing about 5 million (89 percent) of the Medicare beneficiaries enrolled
                                      in HMOs, responded to our questionnaire. During 1996, 1997, and the first 5 months of 1998, these
                                      HMOs reported receiving about 22,000, 32,000, and 21,000 appeals, respectively. Although the number
                                      of appeals increased from 1996 to 1997, the number of managed care enrollees also increased.
                                      Consequently, the average rate of appeals per 1,000 members was approximately the same in both
                                      years.
                                      18
                                        About two-thirds of the plans responding to our survey reported the number of requests received that
                                      they had expedited. On average, these plans expedited about one quarter of the requests.



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                              The number of annual appeals per 1,000 Medicare beneficiaries among
                              HMOs ranged from 0 to 90. Over half of the plans reported between 1 and 10
                              appeals per 1,000 beneficiaries. A number of HMOs reported no appeals for
                              each study year: 17 percent in 1996, 13 percent in 1997, and 9 percent in
                              1998. Nearly all of these HMOs (87 percent) had low Medicare enrollment.
                              There was no similar pattern for plans with the highest appeal rates; they
                              were spread nearly evenly across all plan sizes.19

                              The appeal rate may be rising. Plans reported just over 8 appeals per 1,000
                              beneficiaries in 1996 and 1997, but annualized data from the first 5 months
                              of 1998 indicated more than 10 appeals per 1,000 beneficiaries. Aggregate
                              appeals data may indicate potential problems with a plan’s appeals
                              process, but additional information is needed to assess whether a plan
                              adequately performs this function. A relatively low appeal rate may be the
                              result of a plan’s low denial rate or members who are unaware of their
                              appeal rights. Conversely, a plan that denies many requests or that actively
                              educates members about their rights may experience a relatively high
                              appeal rate. Consequently, appeals data should be considered in
                              conjunction with other factors, such as the rates at which CHDR overturns
                              plans’ appeal decisions and HCFA’s observations of plans’ appeals process.


Some Beneficiaries May        The number of appeals may understate beneficiaries’ dissatisfaction with
Disenroll Instead of Filing   their HMO’s initial decision if some disenroll instead of appealing.
Appeals                       Currently, beneficiaries may disenroll and switch to another plan or
                              Medicare fee-for-service at the end of any month. As we have previously
                              reported, many Medicare HMOs experience high disenrollment rates.20 The
                              extent to which beneficiaries choose to disenroll rather than appeal is
                              unknown. It is clear, however, that disenrollees report less satisfaction
                              with the care they received from their HMOs than enrollees. According to a
                              survey conducted by HHS’ OIG, disenrollees were much more likely than
                              enrollees to say that their primary HMO doctor failed to provide
                              Medicare-covered services.21 The survey showed that 12 percent of the


                              19
                                We divided the plans into four equal groups based on the Medicare beneficiary enrollment in each
                              year data were reported. For example, for 1998 data, the quartiles were (1) 7 to 2,357 members;
                              (2) 2,358 to 8,135 members; (3) 8,136 to 21,200 members; and (4) 21,201 to 250,366 members.
                              20
                               Medicare: Many HMOs Experience High Rates of Beneficiary Disenrollment (GAO/HEHS-98-142, Apr.
                              30, 1998) and Medicare: HCFA Should Release Data to Aid Consumers, Prompt Better HMO
                              Performance (GAO/HEHS-97-23, Oct. 22, 1996). Although some disenrollment is likely caused by
                              beneficiaries’ concerns over the care they received or their plans’ unwillingness to provide requested
                              services, other factors, such as the benefit packages offered by competing HMOs, likely play a role.
                              GAO’s data were unable to identify beneficiaries’ reasons for disenrolling.
                              21
                                HHS OIG, Beneficiary Perspectives of Medicare Risk HMOs, 1996 (OEI-06-95-00430, Mar. 1998).



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                             disenrollees said that their doctors failed to provide covered services,
                             whereas, only 3 percent of enrollees made such an assertion.

                             If some beneficiaries leave their plans instead of appealing adverse
                             decisions, the number of appeals may rise as BBA’s lock-in provisions take
                             effect. Beginning January 1, 2002, beneficiaries will generally be able to
                             change their enrollment decision only once each year outside the annual
                             open enrollment period.22 In 2002, this change must occur within the first 6
                             months of the year. In subsequent years, the change must occur within the
                             first 3 months. After the disenrollment period ends (3 or 6 months),
                             beneficiaries will be locked into their selected plans for the remainder of
                             the year.


HHS’ Inspector General       Studies by HHS’ OIG and by the Medical Rights Center (MRC)23 confirm the
and Advocacy Groups Find     views of several advocacy group representatives that beneficiaries are
Beneficiaries Are Confused   confused about the Medicare appeals process.24 HHS’ OIG reported in
                             March 1998 that 27 percent of Medicare HMO enrollees and 35 percent of
About Medicare Appeals       disenrollees surveyed were uninformed about their appeal rights25—rates
Process                      similar to those found by the Inspector General in 1993.

                             The results of an analysis conducted by MRC are consistent with the OIG’s
                             findings. MRC reported that 40 percent of the 179 beneficiaries who called
                             the center between August 27, 1997, and February 28, 1998, were confused
                             about their appeal rights. According to MRC officials, HMO physicians and
                             customer service staff sometimes compounded beneficiaries’ confusion.
                             For example, MRC handled several cases where HMO customer service
                             representatives allegedly gave out misleading, incorrect, or no information
                             on beneficiaries’ Medicare appeal rights. Representatives of other
                             advocacy groups reported similar experiences and said that they believe
                             many beneficiaries have difficulty understanding the appeals process.


                             22
                               Exceptions are allowed for certain circumstances. For example, individuals who, upon becoming
                             eligible for part A at age 65, enroll in a Medicare+Choice plan may switch to a different plan or
                             fee-for-service at any time during the 12-month period beginning on the effective date of enrollment.
                             23
                              MRC is a national not-for-profit organization that aims to ensure that Medicare beneficiaries have
                             access to quality, affordable health care.
                             24
                              The advocacy groups are the American Association of Retired Persons; Center for Medicare
                             Advocacy, Connecticut; Center for Health Care Rights, Los Angeles; and Legal Assistance to the
                             Elderly, San Francisco.
                             25
                               HHS OIG, Beneficiary Perspectives of Medicare Risk HMOs, 1996. The Inspector General selected a
                             random sample that included enrollees who were enrolled as of June 1996 and disenrollees who had
                             disenrolled between March 1996 and June 1996 for reasons other than death.



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Denial Notices Are        Beneficiaries are supposed to be informed of their appeal rights when they
Sometimes Incomplete or   receive a written notice from their plan denying a service or payment.26
Never Issued              These notices are required to state that the beneficiary has the right to
                          appeal if he or she believes the plan’s initial determination is incorrect.
                          The notices must also tell the beneficiary where and when the appeal must
                          be filed. However, HCFA, OIG, and our own analysis of CHDR appeal cases
                          found numerous instances of incomplete or missing denial notices.

                          HCFA  monitoring reviews indicate that some denial notices were not issued
                          and others failed to mention beneficiaries’ appeal rights. In 1997, HCFA
                          performed 90 monitoring visits to health plans. About 13 percent of the
                          plans reviewed were cited for failing to issue denial notices. Nearly
                          one-quarter of the 90 plans were cited for issuing denial notices that did
                          not adequately explain beneficiaries’ appeal rights. Two studies by HHS’ OIG
                          provide additional evidence that beneficiaries are not always informed of
                          their appeal rights. In one study, the OIG found that in 39 out of 144 appeal
                          cases there was no evidence that the beneficiaries had been sent the plans’
                          initial decisions explaining their appeal rights.27 In another study, the OIG
                          surveyed beneficiaries who were enrolled or had recently disenrolled from
                          a managed care plan.28 According to the results of a survey, 41
                          respondents (about 10 percent) said that their health plan had denied
                          requested services. Of these, 34 (83 percent) said that they had not
                          received the required notice explaining the denial and their appeal rights.

                          Similar deficiencies were found in the appeal cases reviewed at CHDR. Of
                          the 108 CHDR appeal cases reviewed,29 5 contained denial notices that
                          failed to inform the beneficiary of his or her appeal rights. Another 32
                          cases sent to CHDR by the plans lacked the denial notices completely.




                          26
                           In addition, plans are required to explain members’ appeal rights in the marketing materials they
                          distribute.
                          27
                           HHS OIG, Medicare HMO Appeal and Grievance Processes, Review of Cases (OEI-07-94-00283,
                          Dec. 1996).
                          28
                           HHS OIG, Medicare HMO Appeal and Grievance Processes, Beneficiaries’ Understanding
                          (OEI-07-96-00281, Dec. 1996).
                          29
                            We selected these cases from completed decisions at CHDR during the month of October 1998. We
                          randomly selected 27 cases from four case types: (1) expedited decisions upheld by CHDR (459 cases),
                          (2) expedited decisions overturned by CHDR (159 cases), (3) nonexpedited decisions upheld by CHDR
                          (1,772 cases), and (4) nonexpedited decisions overturned by CHDR (500 cases).



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Some Notices Do Not         HCFA requires that denial notices clearly state the specific basis for denial.
Indicate Specific Reasons   HCFA officials said that vaguely worded denial notices hinder enrollees’
for the Denial              efforts to construct compelling counterarguments for their appeals. Also,
                            vague notices may hinder beneficiaries from appealing because they may
                            be uncertain as to whether they are entitled to the requested services.

                            Most notices we reviewed contained general, rather than specific, reasons
                            for the denial. In 53 of the 74 CHDR cases that contained the required denial
                            notices, the notices simply said that the beneficiary did not meet the
                            coverage requirements or contained some other generic reason. It is
                            unclear whether beneficiaries who receive denial notices with nonspecific
                            reasons are less likely to submit written support for their position
                            compared to beneficiaries who receive more detailed notices.
                            Beneficiaries had submitted written support in only 14 of the CHDR appeal
                            cases.30

                            Reconsideration notices written by CHDR personnel provide much greater
                            detail than notices written by plan personnel. For example, in one case,
                            the health plan issued a notice of noncoverage for skilled nursing facility
                            (SNF) services, stating

                            you required skilled rehabilitation services—P.T. eval. for mobility + gait—eval. for ADL’s,
                            speech eval. swallowing—from 2/11/98 and these services are no longer needed on a daily
                            basis.31


                            CHDR’s letter to the beneficiary (upholding the HMO’s denial) stated the
                            following:

                            The case file indicated that while [name] was making progress in his therapy programs, his
                            condition had stabilized and further daily skilled services were no longer indicated. The
                            physical therapy notes indicate that he reached his maximum potential in therapy. He had
                            progressed to minimum assistance for bed mobility, moderate assistance with transfers,
                            and was ambulating to 100 feet with a walker. The speech therapist noted that his speech
                            was much improved by 2/18/98 and that his private caregiver had been instructed on safe
                            swallowing procedures and will continue with feeding responsibilities.


                            Representatives from several advocacy groups told us that in cases
                            brought to their attention, the denial notices were often general and did


                            30
                             In one case, it was impossible to determine whether the beneficiary had submitted a written
                            argument.
                            31
                             “P.T.” stands for physical therapy, “eval.” stands for evaluation, and “ADL’ stands for activities of
                            daily living.



                            Page 16                                  GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
                            B-281220




                            not clearly explain why the beneficiary would not receive or continue to
                            receive a specific service. In August 1997, MRC established a hotline for HMO
                            appeals and analyzed all calls it received during the first 6-month period
                            (179).32 MRC concluded that the explanations found in most plans’ denial
                            notices were unhelpful because of their generality—for example, the
                            services were “not medically necessary.”33


Notices of Discontinued     HCFA  regulations state that whenever plans discontinue services, they must
Coverage Are Often Issued   issue timely denial notices to beneficiaries. HCFA, however, does not
1 Day Before Services Are   specify how much advance notice is required and we found that many
                            plans do not issue denial notices in what many would reasonably consider
Stopped                     “timely.” Although beneficiaries may appeal denied services upon
                            receiving notice, those who receive little advance notice may not be able
                            to continue to receive services because of their potential financial liability.
                            If the beneficiary appeals and loses, he or she is responsible for the cost
                            associated with services received after the date specified in the denial
                            notice. The potential financial burden can be substantial, especially if the
                            denial involves SNF services.

                            In three of the four plans we visited, the general practice was to issue
                            denial notices the day before services were discontinued. We reviewed a
                            number of SNF discharge notices at three HMOs and often found that the
                            notices were mailed (usually by certified or express mail) to the
                            beneficiary’s home instead of being delivered to the facility where the
                            beneficiary resided. In some cases, it appeared that the beneficiary or his
                            or her representative received the notice a few days after the beneficiary
                            had been discharged. Ten of the 25 CHDR cases we reviewed also involved a
                            beneficiary or his or her representative receiving a discharge notice after
                            the beneficiary was discharged from the SNF.34

                            The fourth plan we visited issued SNF discharge notices 3 days prior to the
                            discharge date. This lead time helped ensure that the beneficiary received
                            the notice before the discharge. It also allowed more time for the
                            beneficiary to file an expedited appeal and receive a decision from the
                            plan. Consequently, beneficiaries in this plan who appeal and lose are less
                            exposed to SNF costs incurred during the appeals process.


                            32
                              The hotline operated for 2 hours a day, 4 days a week. At other times, a caller was instructed to leave
                            a message or seek assistance from another organization listed on their denial notice.
                            33
                             MRC, Systemic Problems With Medicare HMOs: Case Studies From the Medicare Rights Center HMO
                            Hotline (Sept. 1998).
                            34
                              There were 27 cases involving SNF discharges, but 2 cases had conflicting data.


                            Page 17                                 GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
                           B-281220




                           Officials in three plans indicated that when a beneficiary is being
                           considered for discharge, a nurse or discharge planner probably would
                           have discussed the issue with the beneficiary well in advance of the
                           discharge. Even when a beneficiary knows a discharge is imminent,
                           however, he or she cannot appeal until a denial notice is officially issued.
                           Officials from the plans we visited told us that, in almost every instance,
                           the decision to discharge a beneficiary from a SNF is made several days
                           before the actual discharge date. Officials from all the plans agreed that, in
                           most instances, such notices could be issued several days prior to the
                           discharge date so that beneficiaries who wished to appeal could receive an
                           expedited appeal decision before the planned discharge date.


                           HCFA’s  biennial monitoring of plans’ appeals process focuses on timeliness
HCFA’s Oversight of        and administrative issues, but we found several important weaknesses in
Plans’ Appeals             the agency’s monitoring procedures. For example, HCFA’s sampling of
Procedures Is Limited      cases to determine whether beneficiaries are appropriately informed of
                           their appeal rights likely misses beneficiaries who were not informed.
                           HCFA’s monitoring also generally excludes the operations of HMO provider
                           groups that may be responsible for making denial decisions and for issuing
                           the required notices. HCFA officials believe that the agency can improve in
                           many of these areas, and in commenting on a draft of this report, HCFA said
                           that it has begun to address these weaknesses. However, to date, HCFA has
                           made little use of the results of its HMO performance reviews to develop
                           overall national trends and improve the agency’s oversight function.


HCFA’s Monitoring          To determine whether plans informed beneficiaries of their appeal rights,
Protocol Systematically    HCFA’s monitoring protocol requires agency staff to review a sample of

Misses Beneficiaries Who   appeal cases. HCFA staff check these case files to determine whether each
                           contains a copy of the required denial notice. However, it seems
May Not Have Been          reasonable to assume that beneficiaries who appeal denials are more
Informed of Their Appeal   likely to have been informed of their rights than beneficiaries who do not
Rights                     appeal. Yet HCFA does not check cases where services or payment for
                           services were denied and not appealed. HCFA might get a better indication
                           of whether beneficiaries were told of their rights if agency staff examined
                           a sample of denial notices from cases that were not appealed.




                           Page 18                       GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
                            B-281220




HCFA and Plans Exercise     Some health plans delegate the responsibility for deciding whether to
Little Oversight of         expedite initial decisions, issuing denial notices, and other operating tasks
Administrative Tasks        to medical provider groups. For example, one plan we visited had
                            delegated the responsibility of issuing service and payment denial notices,
Delegated to Provider       including paying claims, to approximately 250 provider groups with which
Groups                      it contracted. A plan official stated that his plan has never reviewed
                            service denials and does not know how many services its provider groups
                            have denied. The plan has, however, recently developed a monitoring
                            protocol to review service denials and intends to implement it soon.
                            According to several HMO officials, this practice is common in California
                            and is increasing in other parts of the country.

                            Officials also said that HMOs typically exercise little or no oversight over
                            provider groups’ operations and have difficulty ensuring that groups
                            adequately perform the delegated tasks. For example, according to an
                            official from another HMO, provider groups on the West Coast expect plans
                            to grant them the authority to issue denial notices because they are at
                            financial risk for the services they provide. To contract with these groups,
                            his plan must delegate that authority even though the practice is not
                            desirable from his HMO’s perspective. He said that provider groups often do
                            not send the plans copies of issued denial notices, although the plans
                            request them. The official estimated that his plan receives only about
                            30 percent of the denial notices issued by their provider groups. He added
                            that his plan does not review the notices it does receive.

                            Moreover, according to a HCFA official, HCFA does not generally monitor
                            HMO provider groups. Because provider groups may not submit requested
                            information to HMOs and HCFA does not normally monitor provider groups
                            directly, it is likely that no one reviews many of the initial
                            decisions—including expedited decisions—made by these groups. A 1998
                            study done for HCFA noted that the delegation of authority to provider
                            groups is problematic because health plans do not exercise sufficient
                            control over the delegated functions.35 The report recommended that HCFA
                            pay closer attention to this issue.


HCFA Has Provided           Although HCFA has provided plans with general guidance, such as model
Limited Guidance to Plans   language for denial notices, it has not produced specific guidelines to
on Expedited Appeals        ensure consistent implementation of the expedited appeals process.
                            Further, without clear guidelines on what should be expedited, HCFA has
Process
                            35
                             Bailit Health Purchasing, LLC, The Medicare Managed Care Compliance Monitoring Program:
                            Recommendations for Modification and Improvement (Jan. 28, 1998).



                            Page 19                              GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
                              B-281220




                              no way of determining whether plans are expediting initial decisions and
                              appeals appropriately. HCFA has not produced criteria or examples for
                              HMOs to follow when deciding whether the standard appeal time frames
                              could seriously jeopardize a beneficiary’s health or life. In the absence of
                              such criteria, Medicare HMOs have a wide latitude to determine whether a
                              beneficiary’s request for an initial decision or appeal should be expedited.

                              Receiving no specific guidance from HCFA, several California HMO and
                              provider industry representatives formed a work group and developed
                              clinical criteria for expedited initial decisions and appeals. In
                              January 1998, the HCFA region responsible for Arizona, California, and
                              Nevada provided the work group’s criteria to all Medicare HMOs in those
                              three states. HCFA officials said they are not aware of similar efforts in
                              other regions. We found, however, that at least one Florida HMO had
                              incorporated much of the California work group’s criteria into its own
                              procedures—possibly because the HMO also operated in California.

                              Without better guidance from HCFA, some cases that should be expedited
                              may not be. In our review of cases sent to CHDR, we examined 42 appeals
                              involving denied services that HMOs had not expedited. CHDR reviewers
                              determined that seven (17 percent) of these cases should have been
                              expedited. (CHDR expedited these cases for its own review process.)


HCFA Makes Little Use of      Staff from HCFA’s central and regional offices told us that the agency has
Available Data for National   made little use of its monitoring reports as an overall program
Program Management            management tool. Each report documents the results of HCFA’s biennial
                              performance review of a plan and summarizes its compliance with
                              Medicare regulations. Aggregating the findings from the individual
                              monitoring reports could help HCFA monitor the relative performance of
                              plans, identify variations among regions, and study national trends.
                              However, when we requested all of the 1997 monitoring reports no one at
                              HCFA’s headquarters had a complete set. We were told that we would have
                              to request them from each region.

                              Shortly after we requested the reports from the regions, the Health Plan
                              Purchasing and Administration Group in HCFA’s central office began
                              collecting from the regional offices all 1996 and 1997 monitoring reports.
                              According to HCFA officials, agency staff are now analyzing the information
                              in the reports.




                              Page 20                      GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
                         B-281220




                         HCFA  is planning to develop a health plan management system that will
                         provide information to central and regional office staff and will aid plan
                         and program oversight. The system will include information on appeals.
                         HCFA had expected to complete the data design phase by now but has
                         fallen behind schedule. According to the project manager, the system will
                         not be operational until late 1999 or early 2000.


HCFA Has Not Required    The need for both HCFA and Medicare beneficiaries to have information on
Plans to Collect and     HMO appeals is well recognized. In 1996, and again in 1998, HHS’ OIG

Report Data on Appeals   recommended that HCFA require managed care plans to report data on
                         appeals, such as the number of cases, the number resolved internally and
                         externally, issues involved, and the time needed to resolve cases.36 Also, in
                         implementing its expedited process, HCFA is requiring plans to report data
                         on expedited appeals. Further, BBA requires plans to disclose information
                         on the number and the disposition of appeals to interested Medicare
                         beneficiaries.

                         On February 10, 1999, HCFA issued an operational policy letter that
                         establishes the guidance for managed care plans to follow in collecting
                         appeals data and making that information available to Medicare
                         beneficiaries. Plans will report the number of appeals per 1,000 Medicare
                         beneficiaries. Each plan’s rate will be based on its contract market.37 Plans
                         will begin collecting and maintaining appeals data beginning April 1, 1999.
                         Data collection periods will be based on a rolling 12-month period. (The
                         prior 6 months of data are added to the next 6 months of data in order to
                         come up with a 12-month data collection period.) The first 6-month period
                         will begin April 1, 1999, and end September 30, 1999. Plans will report
                         results from the first 6-month period on January 1, 2000.

                         HCFA, however, has not provided guidance on the type of appeals data
                         plans should collect and report to HCFA. According to officials in HCFA’s
                         central office, the agency has formed a work group—consisting of plan
                         representatives, advocacy representatives, and program officials—to
                         develop appeals data requirements. HCFA expects to finalize these
                         requirements later this year. Meanwhile, some HMOs may be waiting to
                         receive HCFA’s guidelines before they implement systems to track their
                         appeals data. Although all the plans that responded to our survey reported

                         36
                            HHS OIG, Medicare HMO Appeal and Grievance Process: Overview (OEI-07-94-00280, Dec. 1996), and
                         Medicare’s Oversight of Managed Care: Monitoring Plan Performance (OEI-01-96-00190, Apr. 1998).
                         37
                          Contract market implies either reporting by contract or by a market area within a contract. This
                         determination will be made by HCFA.



                         Page 21                                GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
                      B-281220




                      the total number of appeals upheld and overturned, only about two-thirds
                      were able to break down their appeals into more specific service
                      categories, such as nursing home care and emergency room use.


                      Medicare beneficiaries have access to a multilevel appeals process that
Conclusions           allows them to challenge HMO decisions to deny services or payment for
                      services. Relatively few beneficiaries—about 9 out of every 1,000 managed
                      care enrollees—appeal each year. Some beneficiaries may not appeal,
                      however, because they are unaware of their appeal rights or confused
                      about the process. Evidence from a variety of sources—HCFA monitoring
                      reports, studies by HHS’ OIG, and our review of cases at plans and at
                      CHDR—indicate that plans do not always inform beneficiaries of their
                      appeal rights as required. In some cases, denial notices cite nonspecific
                      reasons for the denial, making it more difficult for beneficiaries to
                      challenge their plan’s decision. In other cases, beneficiaries may be
                      unnecessarily exposed to substantial health care costs because notices are
                      not issued in a timely fashion. Furthermore, the agency has not issued
                      specific guidance as to the types of cases plans should expedite.

                      HCFA  reviews plans’ implementation of the appeals process, but its
                      monitoring protocol exhibits several weaknesses. For example, HCFA does
                      not know whether provider groups have satisfactorily implemented the
                      required appeals process because it exercises little oversight over provider
                      group operations. The type of cases HCFA samples to determine whether
                      beneficiaries were informed of their appeal rights likely systematically
                      misses beneficiaries who were not informed. Further, the agency has not
                      provided plans guidance on the types of appeals data they should collect
                      and report to HCFA. HCFA agrees that it needs to strengthen its oversight of
                      health plans’ appeals process and noted that the agency has several
                      initiatives under way.


                      To help ensure that the appeals process provides adequate protection to
Recommendations       Medicare beneficiaries, the HCFA Administrator should take the following
                      actions:

                  •   Provide more explicit denial notice instructions to plans. Denial notices
                      should explain the coverage criteria and state the specific reason or
                      reasons why the beneficiary did not meet the criteria.




                      Page 22                      GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
                         B-281220




                     •   Set specific timeliness standards for certain types of denial notices, such
                         as discontinued SNF care services, to allow beneficiaries reasonable time to
                         obtain an expedited appeal decision.
                     •   Develop criteria for plans to use in determining when initial decisions and
                         appeals should be expedited.

                         To improve the agency’s monitoring of the appeals process, the HCFA
                         Administrator should take the following actions:

                     •   Require each plan to collect sufficient information from its provider
                         groups so that HCFA staff can, during the course of a normal biennial
                         performance review, determine whether the plan and its provider groups
                         satisfactorily implemented the required appeals process.
                     •   Require agency staff conducting performance reviews to sample a number
                         of denied cases that were not appealed to determine whether beneficiaries
                         were informed of their appeal rights.
                     •   Use the data the agency collects during plan performance reviews to
                         assess the relative performance of plans, and develop strategies for better
                         plan monitoring and program management.

                         To ensure that appeals data are available to HCFA and Medicare
                         beneficiaries, the Administrator should develop requirements for the type
                         and format of appeals data plans must collect and make available.


                         HCFAagreed with our finding that its oversight of health plans’ appeals
Agency Comments          process needs to be strengthened and generally agreed with our
and Our Evaluation       recommendations. (See app. II for HCFA’s written comments regarding our
                         recommendations.) The agency outlined several initiatives it has recently
                         undertaken to better protect beneficiary rights. Some of these initiatives
                         may be implemented shortly; others are in the early planning stage.

                         HCFA  expressed concern, however, about our recommendation that the
                         agency develop criteria to help plans determine when initial and appeal
                         decisions should be expedited. HCFA said that a further refinement of the
                         current general criteria might inadvertently exclude unspecified standards.
                         HCFA said that it would explore possible options regarding the criteria, but
                         that it would proceed cautiously to avoid unanticipated problems. We
                         disagree with the premise that further refinement of the criteria would
                         inadvertently limit beneficiary access to expedited initial and appeal
                         decisions. As noted in this report, specific clinical criteria have been
                         developed and used by plans in at least one HCFA region. HCFA could



                         Page 23                      GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
B-281220




develop specific criteria, to be implemented nationwide, that are
understood to be an elaboration of the current general criteria and not a
replacement for them.

In addition, HCFA provided several technical comments, which we
incorporated as appropriate.


As agreed with your office, unless you publicly announce the contents
earlier, we plan no further distribution of this report until 1 day from the
date of this letter. At that time, we will send copies to the Honorable
Donna Shalala, Secretary of HHS; the Honorable Nancy-Ann Min DeParle,
Administrator of HCFA; and interested congressional committees and
members. We will also make copies available to others on request.

Please contact me at (202) 512-7119 or James Cosgrove, Assistant
Director, at (202) 512-7029 if you or your staff have any further questions.
This report was prepared by Cam Zola, Richard Neuman, and Beverly
Ross.




Laura A. Dummit
Associate Director, Health Financing
  and Public Health Issues




Page 24                       GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
Page 25   GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
Contents



Letter                                                                                                 1


Appendix I                                                                                            28
Scope and
Methodology
Appendix II                                                                                           30
Comments From the
Health Care Financing
Administration
Table                   Table 1: Medicare Risk HMO Internal Appeals, 1996 to May 1998                 12


Figures                 Figure 1: Medicare Appeals Process                                             8
                        Figure 2: Elapsed Time for Major Events in the Appeals Process                11




                        Abbreviations

                        ALJ       administrative law judge
                        BBA       Balanced Budget Act of 1997
                        CHDR      Center for Health Dispute Resolution
                        HCFA      Health Care Financing Administration
                        HHS       Department of Health and Human Services
                        HMO       health maintenance organization
                        MRC       Medical Rights Center
                        OIG       Office of Inspector General
                        SNF       skilled nursing facility


                        Page 26                     GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
Page 27   GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
Appendix I

Scope and Methodology


             To obtain information on plan-level appeals handled by HMOs during 1996,
             1997, and the first 5 months of 1998, we surveyed all (307) Medicare HMOs
             that were active as of May 31, 1998. We obtained responses from 250 plans
             (81.4 percent).

             We visited three judgmentally selected HMOs—one in California and two in
             Florida. We selected these plans based on (1) geographic location, (2) high
             1997 disenrollment rates, and (3) high Medicare enrollments. Our visit to
             one Florida HMO coincided with a monitoring visit by HCFA’s region IV staff.
             During our visits, we discussed the appeals process with plan officials and
             reviewed a limited number of cases at three of the locations. The cases
             included standard appeals and expedited appeals that were upheld and
             overturned at the plan level within the 6 months prior to our visit. Each
             case reviewed was discussed with a plan official responsible for the plan’s
             appeals process. In addition, we made a site visit to an HMO in Maryland
             during a HCFA monitoring visit. Our visit to the Maryland HMO was limited
             to overseeing the monitoring team’s review of appeal cases and several
             discussions with plan officials.

             We visited the two HCFA regional offices (region IX in San Francisco,
             California, and region IV in Atlanta, Georgia) responsible for the three
             plans we visited. We discussed the appeals process and the monitoring
             effort with appropriate officials in each region. We also spoke with
             regional personnel in HCFA’s region X about the appeals process and HCFA’s
             monitoring effort and results. In addition, we obtained from HCFA a
             summary spreadsheet that showed all the monitoring reports completed in
             1997 and summarized plan compliance with Medicare requirements. From
             this list, we selected and reviewed the monitoring reports of plans that
             indicated deficiencies in the categories related to the appeals process,
             denial notices, or both.

             With assistance from CHDR we randomly selected and reviewed 108 appeal
             cases that had been adjudicated by CHDR in 1998 and had not been sent to
             storage as of October 1998. We developed a data collection instrument and
             specific criteria for evaluating the case file information. A CHDR analyst,
             who reviewed each case and recorded the review results, used this
             instrument and criteria. We reviewed the results of over half of the 108
             cases to ensure the data were recorded accurately and met our evaluation
             criteria.

             We discussed HCFA’s appeal policy and practice with HCFA officials and
             representatives from five advocacy groups representing Medicare



             Page 28                      GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
Appendix I
Scope and Methodology




beneficiaries in health plans. In addition, we reviewed a number of HHS OIG
reports covering several aspects of Medicare’s appeals process in HMOs.
Also, we reviewed a report done by the Medicare Rights Center that
discussed systemwide problems with Medicare HMOs.

Our office of General Counsel reviewed the results of a class action
lawsuit and the resulting appeal by HCFA before the 9th U.S. Circuit Court
of Appeals.




Page 29                      GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
Appendix II

Comments From the Health Care Financing
Administration




              Page 30   GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
Appendix II
Comments From the Health Care Financing
Administration




Page 31                         GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
Appendix II
Comments From the Health Care Financing
Administration




Page 32                         GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
Appendix II
Comments From the Health Care Financing
Administration




Page 33                         GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
Appendix II
Comments From the Health Care Financing
Administration




Page 34                         GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
           Appendix II
           Comments From the Health Care Financing
           Administration




(101751)   Page 35                         GAO/HEHS-99-68 Protecting Medicare Beneficiary Rights
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