Consumers can gain improved insight since plan administration grievances illustrate how well the HMO handles its consumer affairs where benefit denial grievances indicate the denial of coverage or referrals for enrollees. An additional suggestion provided by CPR last year was to include the number of enrollees and the grievance reversal rates of HMOs. This is essential information that should be included in OCI's yearly report. Reversal rates of grievances can indicate an HMOs aggressive interpretation of benefits motivated to avoid payment of costly services rather than what is medically necessary or could indicate the HMO's careful scrutiny of grievances, their merits and specifics of the enrollee's situation. CPR feels that the exclusion of this data eliminates a critical piece of information that consumers could use.
Health care is at a crossroad and is still evolving.
To remain abreast requires diligent examination and improvement of the information necessary for consumers. OCI currently provides data from the last two years but performs no analysis on HMOs performance from year to year. The majority of the HMOs had an increase in grievances. Several reasons could be possible. Enrollees may have become more aware of the grievance process and therefore are filing more often, or HMOs are denying more services and benefits to enrollees.