Date: July 8, 2009
For more information contact: Jim Guidry, (608) 264-6239 or jim.guidry@wisconsin.gov

Commissioner Releases Consumer Grievance Information

Madison, WI—The Office of the Commissioner of Insurance has published its annual report on the number of grievances for managed care health plans for 2008. The information submitted by insurers is contained in the OCI publication Consumer's Guide to Managed Care Health Plans in Wisconsin.

"I want Wisconsin consumers to have the information they need to make good decisions on the purchase of health insurance," said Wisconsin Insurance Commissioner Sean Dilweg. "Grievance information is one tool to assist consumers and businesses in the market for health insurance."

All health insurance plans, including all managed care plans and Limited Service Health Organizations (LSHOs), are required to have an internal grievance procedure for policyholders who are dissatisfied with their plan. Health plans must provide each enrollee with complete and understandable information about how to use the grievance procedure. An enrollee has the right to appear in person before the grievance committee and present additional information.

Managed care plans and LSHOs are required to report to OCI the number of grievances they had in the previous year. Managed care plans include HMOs and preferred provider plans (PPPs). As in 2007, PPPs had the largest number of grievances filed in 2008. PPPs reported 48.7 grievances filed per 10,000 enrollees for a total of 4,075 grievances. In 2007 PPPs reported 49.9 grievances filed per 10,000 enrollees or a total of 4,171. HMOs reported 20.5 grievances filed per 10,000 enrollees (21.5 in 2007) or 2,911 total (2,789 in 2007). LSHOs reported 0.4 grievances per 10,000 enrollees (3.3 in 2007) or 43 total (74 in 2007) grievances filed.

All health plans are also required to have a separate expedited grievance procedure for situations where the medical condition requires immediate medical attention. Health plans are required to resolve an expedited grievance within 72 hours after receiving the grievance.

Grievances are only part of the dispute process. Consumers can also file a complaint with OCI. A complaint may be filed by mail or on-line using OCI's on-line complaint form. Additionally, disputes involving medical necessity or experimental treatment decisions are eligible for independent review. The health plan is required to provide enrollees with information on the independent review process. The independent review process provides the enrollee with an opportunity to have medical professionals who have no connection to the health plan review the dispute.

OCI offers a number of publications for consumers that provide more information on settling disputes with health insurers. In addition to the Consumer's Guide to Managed Care Health Plans in Wisconsin, the publications Consumer's Guide to Grievances and Complaints and the Fact Sheet on the Independent Review Process in Wisconsin also provide valuable information for consumers. The publications can be ordered free from the agency by writing to OCI Publications, P.O. Box 7873, Madison, WI 53707-7873, calling 800-236-8517 or visiting the OCI Web site at http://oci.wi.gov.

Created by the Legislature in 1871, Wisconsin's Office of the Commissioner of Insurance (OCI) was vested with broad powers to ensure that the insurance industry responsibly and adequately met the insurance needs of Wisconsin citizens. Today, OCI's mission is to lead the way in informing and protecting the public and responding to its insurance needs.