RESOLUTION TIME FOR MEMBER GRIEVANCES

Meeting State Requirements With a Plan-Wide Effort

Sometimes poor service can lead to more than just unhappy members. This plan was performing far below its state's department of health (DOH) standard for the timely resolution of grievances or appeals. Unless the plan demonstrated a clear ability to resolve grievances in a timely manner, it would be declared out of compliance with state regulations.

The targeted population consisted of all members that had filed a grievance or appeal with the health plan. The performance measure was the percentage of grievances that were resolved within 30 days. To determine its baseline, the plan used data from December 1995 to establish a compliance rate of 33%. The benchmark and goal were established by the DOH: 100% of grievances must be resolved within 30 days. The plan also used its existing information system to create a database for this quality improvement initiative. Using this database, the plan tracked grievance resolution time on a daily basis and generated monthly reports. It reported on its compliance rate on a quarterly basis.

The member grievance area handled all grievances, complaints, and hearings. The plan's system involved logging cases into the member grievance area at the time of the initial grievance. Each case was then logged out to other departments (e.g., customer service, health care management, membership, sales, and claims) for investigation, and subsequently logged back into the member grievance area. A barrier analysis was conducted by the quality improvement team, which included biostatisticians from the local university. Most delays were due to backlogs in the member grievance area, but other departments were also contributing to the problem.

In the first year of the initiative the plan focused on three types of interventions:

• Policies and procedures
• Staffing
• Staff education

The plan began by breaking out grievances into three levels of appeals, as defined by the DOH. Previously, levels had been inappropriately mixed. Level 1 grievances were handled by an internal review; level II grievances were reviewed by a three-person panel of a medical director; customer service director/manger, and an outside subscriber; and level III grievances were heard by the DOH.

The plan had to overcome a major difficulty in setting up the level II grievance hearings. DOH dictates that these hearings must include one plan staff member (usually a customer service manager/director), one health care management medical director, and one outside subscriber. A limited pool of staff members and subscribers available for these hearings made scheduling difficult. In response, the plan recruited and trained more plan staff to participate in the level II hearings. The member grievance area staff then asked the sales department to help recruit additional subscribers to participate in level II grievance hearings. Eventually 20 subscribers and 50 staff members were identified for participation in the hearings.

Some delays were caused by members rescheduling hearings; a new policy required members to notify the plan if they were going to cancel their appearance at a level III hearing.

The plan required medical directors to vote on all level II grievances. This helped to expedite resolution time and provided education for internal care managers.

The plan also began requiring senior physician advisors, both employees and consultants, to participate in level I grievances in order to decrease the number of cases going to level II.

TEAMWORK Customer service is not the only department responsible for customer service. The success of this intervention depended on the contributions of many departments. The importance of the 30-day requirement was brought to the attention of the health care management, membership, sales, and claims departments in addition to customer service.

Staffing issues were addressed within the grievance area. A grievance administrator was added by reassigning a staff member from another area. A full-time secretary was added. Complaints that weren't grievances were offloaded to another department.

The plan actually measured its results on a quarterly basis, with adjustments to its interventions as the year proceeded. The first year of the initiative, 1996, showed a continual rise in the rate of grievances resolved within 30 days. Each quarter's rate exceeded the last. By fourth quarter of 1996 the compliance rate was 86%, a significant improvement.

The plan continued to reinforce the need for 100% turnaround of grievances within 30 days. Cases not meeting the turnaround time requirement were becoming the exception. The plan investigated these on a case-by-case basis. The plan also added another grievance administrator.

The 1997 results showed statistically significant improvement compared with the previous year's. First quarter results showed a 98% compliance rate. This rate was statistically unchanged throughout the year, with subsequent quarters showing rates of 95%, 98%, and 98.6%.

The plan continued with its monthly analysis and case-by-case review of exceptions. It also developed and implemented a new training intervention for the plan's departments, and created a new acknowledgment letter.

The plan began its new training intervention by conducting grievance overview training sessions for various departments. In addition, the plan provided guidance to subscriber members in interpreting plan documents, and for participating on the level II grievance committee. The plan also developed an informational letter to be sent to members who had new grievance inquiries; this would be sent within two business days of the receipt of each inquiry.

Analysis at this point showed that formulary grievances were the most common type of grievances that did not meet the resolution turn-around goal of 30 days. In response to this information, the plan established a procedure for the pharmacy area medical director to review formulary appeals prior to scheduling level II grievance hearings.

In an attempt to further reduce the number of level II grievances, the plan also involved case managers in the level I grievance process to determine possible case management interventions.

The 1998 data showed compliance rates starting in the first quarter with 96.3% and ending in the fourth quarter with 99.3%. Besides showing significant improvement, the plan essentially met its goal and was in substantial compliance with the state DOH.

The results of the initiative have been sustained into 1999, with compliance rates close to 100%.

This plan found that the quality improvement process itself was enormously beneficial. Personnel that were brand new to managed care found the NCQA and QIA form especially beneficial. Through the use of the form, they learned the importance of baseline measurement, analysis, and remeasurement. The plan now uses this form for all initiatives, whether or not it is part of a formal NCQA survey.