FL consumer assistance program puts agency clout behind efforts to resolve disputes with HMOs
Florida Consumer Program / HMO
December 31, 1997
Florida is launching a statewide ombudsman program for managed care consumers that will offer the same kind of assistance with access problems that many consumers can get from their local consumer advocacy groups.
The major advantage of a state-sanctioned program over many voluntary local programs, said Sylvia Torgan, founder of Broward County’s HMO Patient Advocate Committee and a driving force behind the legislation that created the program, is that the power of a state regulatory agency is behind efforts to resolve disputes between health plans and consumers.
Under the aegis of the Agency for Health Care Administration (AHCA), volunteer committees of medical and other professionals as well as consumer representatives will operate in 11 districts of the state. The volunteers will investigate complaints and assist consumers in filing grievances and appeals against their health plans.
Broward County’s private and voluntary HMO Patient Advocate Committee performed these tasks for 10 years, according to Ms. Torgan, but she believes the agency’s clout will help make managed care plans more responsive. A state ombudsman program also helps keep the agency "patient-centered," she said.
Sandy Berger, spokeswoman for AHCA agreed that it will be helpful for the state agency to be in closer contact with the appeals and grievance process. "The biggest advantage is that the agency is aware of complaints.
"We will be the intake body and also the regulating body. The complaint is in our system and we can track it." If an intervention is required, "we’re in a better position to know the history and we have authority," she said.
The state operates hotlines for consumers who have questions about their managed care plans or problems. The hotlines receive about 5,000 calls per month, according to Ms. Berger. Less than 10% of those calls require a follow-up beyond a call to a plan. Some of those unresolved problems would be referred to the ombudsman committee, which might assist consumers in filing appeals. Florida is one of a handful of states that also has an independent appeals process for consumers who have exhausted a plan’s internal appeals mechanism. Ombudsman committee members would also assist consumers with that external appeals process.
Each ombudsman committee must include at least eight professionals— four volunteer physicians, one registered nurse, one social worker, one attorney and one psychologist. The committees will have from nine to 16 members and must include at least one consumer.
AHCA will appoint the first three members and those appointees will select the rest of the committee, which will number from nine to 16.
The power of a state regulatory agency is behind efforts to resolve disputes between health plans and consumers.
As of Nov. 1, the first three members of Broward County’s committee, two physicians and a consumer activist, had been appointed from a pool of 150 applicants. The ombudsman program will be rolled out gradually in the rest of the state once it is piloted in Broward County.
Under the law creating the program, no one who is employed or affiliated with a managed care plan may serve on the committee. This restriction was meant to prevent conflicts of interest, but it is making it difficult to find physicians and other professionals who are free to serve, state officials said. As a result, the most likely physicians to serve on the committees are retired physicians.
Florida HMOs and others question whether states need this other level of bureaucracy. Richard Dorff, executive director of the Florida Association of HMOs, said his group is "in favor of anything that helps the consumer if it’s needed," but "I don’t believe (the ombudsman program) is necessary," he said. "The HMO industry has a long established internal grievance process that’s extremely effective, one that allows patients to take their concerns all the way to the board of directors and then allows them to appeal externally."
AHCA will act as a gatekeeper in the ombudsman program, screening complaints and referring HMO members to ombudsman committees when it is deemed necessary. A centralized system will help give the agency statewide information about how problems are resolved.
But, Ms. Torgan worries that a gatekeeping system for referring complaints to local committees will slow down response time to complaints that aren’t strictly emergencies. Under Florida law, emergency complaints must be addressed within 24-48 hours. Ms. Torgan said legislation will be introduced in the next session that will allow local committees to receive complaints directly and will give them more authority to do site visits as part of their investigations. More funding is also being sought for the committee.
Implementation of the program, passed in 1996, was stalled until legislation could be passed protecting the confidentiality of medical records of HMO members who seek assistance from the ombudsman program. Because it is a state program, there were concerns about patient files being subject to public disclosure laws.
Program covers all MCOs
Florida appears to be the first state to develop an ombudsman program for members of all managed care organizations whether they are in Medicaid, Medicare or commercial plans, according to Sigrid McGinty, a researcher with the General Accounting Office, who is working on a report on how five states handle consumer complaints against managed care.
Several states provide Medicaid managed care members with assistance when they have grievances, often using enrollment brokers to handle complaints about service or care from Medicaid clients.
Contact Ms. Berger at 850-488-1295, Mr. Dorff at 305-671-5437, and Ms. Torgan at 561-338-5032.
FL consumer assistance program puts agency clout behind efforts to resolve disputes with HMOs
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