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FOR RELEASE: December 1, 2000
HMO Regulation a Health Priority
A proposal to move the primary regulatory authority of Health Maintenance Organizations (HMOs) from the Oklahoma State Department of Health to the Insurance Department could impact consumers' health, says the Acting Director of the Oklahoma State Department of Health.
“HMOs are more than mere payers of medical bills,” said Jerry Regier, Acting Director of the Oklahoma State Department of Health (OSDH) and Secretary of Health and Human Services. Regier was responding to recent criticism of the OSDH's oversight of HMOs and a proposal by the state Insurance Department to take over primary regulatory authority of HMOs.
“An HMO provides a package of health care services through a network of physicians and hospitals. It both pays for and provides or arranges for the medical care, unlike an insurance company, which only pays medical claims,” Regier explained. “We believe the public is best served by our agency, which has doctors and nurses available to review medical records and those 'quality of care' issues that contribute to assuring comprehensive health care.”
Regier said the OSDH has an effective system in place to handle HMO complaints. Consumers can call a statewide toll-free hotline, 1-800-811-4552, to make a complaint about an HMO. OSDH staff screen these calls and try to resolve with the HMO and complainant those complaints that involve simple issues. For more complicated complaints, callers are advised to file a written complaint with the OSDH or HMO. Those filed with the OSDH are forwarded to the HMO, which has seven days to acknowledge receipt of the complaint. The HMO then has 120 days to resolve the complaint. All correspondence must be copied to the OSDH, which tracks progress of the complaint's resolution. Once the HMO has concluded the process and a resolution has been reached, the OSDH reviews the file to determine if any rules violations occurred. In some instances, the HMO may be required to demonstrate why it was not in violation of any rules, or it may be required to develop a plan of correction so the error does not reoccur.
“Although the state Insurance Department says more than half of their complaints involve HMOs, our statistics indicate otherwise,” Regier observed. “For calendar year 1999, we received 459 written complaints on HMOs, with 45 percent, or only about 206, of those forwarded from the Insurance Department.”
An HMO's history of failure to resolve conflicts could result in suspension or revocation of its license or administrative penalties. In 1999, of the 459 written complaints filed with the OSDH, 330 were resolved in the member's favor and 84 were not. In 45 cases, the HMO member decided not to pursue the complaint, or the complaint was against an insurer or other company that was not an HMO.
“The State Insurance Department and the OSDH do have a common goal to protect the public,” Regier said. “While our agency is required by law to make sure an HMO delivers a quality health product, the law also provides that the Insurance Department must assess if HMOs are financially capable of meeting their obligations. The law requires that prior to issuing a license to an HMO, the OSDH must forward the application to the Insurance Department for review of the applicant's 'fiscal responsibility' and 'fiducial integrity'.”
A review of the HMO applications forwarded in recent years to the Insurance Department indicates:
Regier said the Insurance Department has provided sporadic quarterly reports to the OSDH regarding the financial conditions of HMOs. “We found that in the majority of these reports, the Insurance Department expressed 'no concern' or 'no action required',” Regier said. “In those instances when a concern has been raised, we have pursued that issue with the HMO and we have sent copies of our correspondence to the Insurance Department in an effort to make certain their staff know we responded to the concern,” he emphasized.
“We share the Insurance Department's interest to ensure that HMO members receive appropriate assistance. Just as the Insurance Department receives calls about HMOs, our agency receives calls about insurers. In 1996, we developed a protocol for information sharing between our agencies. Unfortunately, the Insurance Department declined to respond to that agreement,” Regier said. “Even so, we continue to be interested in working with the Insurance Department to provide the services necessary to respond to HMO members' needs – including working together to educate and inform consumers on the process for handling their HMO complaints.”
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