What the statutes mean

The insurance commissioner has rules that attempt to insure that patients of preferred provider organizations (PPO) have adequate access to health care services, know about the services that are available, and have a procedure to deal with grievances or complaints.

Excessive distances

Preferred provider plans must have chiropractors on their panels that are within 30 minutes travel time of the patient’s place of residence.

– However, the PPO may ignore this requirement if they are selling health care services on a group basis to an employer and a chiropractor is available either within the county or within 30 minutes’ travel time of the employment location.

– A PPO may also ignore this requirement if the patient is informed in writing of the location of all chiropractors and makes a written request for coverage despite the fact that there is not a chiropractor within 30 minutes of their home or work .

Continuity of coverage

A preferred provider plan that is offered on a group basis must extend the enrollment periods for a person who wants to enroll in the plan, but who wants to finish their treatment plan with a chiropractor who is not part of the PPO. The PPO is not allowed to set standards for these people that are any stricter than the standards for those who enroll during the normal enrollment period.

– The PPO may require the person to request an extended enrollment period during the normal enrollment period and to explain their problem and the expected duration of their course of treatment.

– The PPO is not required to extend enrollment opportunities to a dependent of a group member unless the group member and any other dependents also receive an extension.

– The PPO may limit the extension of the enrollment period for a group member and dependents to 90 days after the effective date of the contract.

– The PPO may not collect premiums, co-pays or deductibles until the person is enrolled. Likewise, the person does not have any coverage until they are actually enrolled in the plan.

Plan information

Preferred provider plans must provide the following information to each of its members:

• The services covered.
• A definition of emergency services if emergency services are covered differently than other services.
• The specific location of providers for each type of service.

• The cost of the plan.
• Enrollment procedures.
• Limitations on benefits.

This information must be provided to employers at least 30 days before the first day of each enrollment period. The PPO must ensure that employers make this information available to all of their employees in time for them to make an informed choice among available plans. If a PPO plan is offered on an individual basis, the information must be given at the time of application.

All of this information must be legible, complete, understandable and presented in a meaningful sequence. Exclusions and limitations must be listed in a single section and must define words and expressions which are not commonly understood or whose commonly understood meaning is not intended.

Grievance procedure

What is an PPO required to do when they receive a grievance?

An PPO is required to print its grievance or complaint procedure in its insurance materials. When they receive a grievance/complaint from one of its members they are required to investigate it. However, there is no requirement that an unbiased person investigate the grievance/complaint so there is no assurance that the PPO will do anything but confirm its original opinion.

In addition to printing the grievance procedure in its insurance materials, the PPO must also notify the patient that they have the right to file a grievance every time they deny a claim or if they should try to terminate the patient’s insurance coverage. They notice is supposed to state the specific reason that the claim was denied. Instead of giving a clinical reason for a claim denial, most PPO’s hide behind a general denial that the service did not meet the “medical necessity” definition of their policy.

How long does an PPO have to resolve a grievance or complaint?

The PPO is supposed to resolve all grievances within 30 calendar days of receiving the grievance. If they are unable to resolve the grievance within 30 calendar days, they are allowed to extend the time period an additional 30 calendar days if they notify the person who filed the grievance, in writing, that they have not resolved the grievance, when they expect to be able to resolve the problem, and the reason why additional time is needed.

Does the patient have the right to speak to someone personally about their problem?

Every PPO must have a method that allows their member to personally discuss their problem before their grievance committee to present written or oral information and to question those people responsible for making the decision that resulted in the grievance. When the patient requests a personal meeting, the PPO must inform the patient of the time and place of the meeting, in writing, at least 7 calendar days before the meeting. There is nothing to prohibit a patient from bringing their chiropractor along with them to this meeting.

What if the complaint involves an urgent need for care?

In urgent care situations the PPO must develop a separate grievance procedure. They must have an internal procedure in place that allows them to resolve an urgent care situation grievance within 4 business days of receiving the complaint.

What records must an PPO keep of the grievances it receives?

Preferred provider organizations must record, retain, and report records for each complaint and grievance in accordance with all of the following requirements:

• Each HMO must keep and retain for at least 3 years a record for each complaint and grievance submitted to them.

• Each contract or agreement with a chiropractor must contain a provision under which the chiropractor must identify complaints or grievances in a timely manner and forward these complaints or grievances in a timely manner to the PPO for recording and resolution.

Practical advice

PPO’s are constantly reporting that patients are overwhelming satisfied with the care they receive. From the anecdotal information received by the WCA, this does not seem to be the case. The “satisfaction” reported by the PPO may be due to the following reasons.

• The numbers are exaggerated because the PPO’s report the “satisfaction” of all of their members, whether or not the individual actually had to use the services of a PPO doctor. Since a large percentage of people never have reason to visit a doctor during the year, or their problem is not complicated and requires only routine care, it stands to reason that all of these individuals would be “satisfied”.

• Chiropractic patients are not separately surveyed. Because there is less variability in the methodology used by medical doctors to treat their patients it is likely that the “satisfaction” with these doctors would be more uniform. Because the chiropractic profession does not have any practice protocols and there may be financial incentives to limit the care patients receive in a PPO environment, it would not be unusual to find that there would be more variability with the “satisfaction” of chiropractors.

• Patients do not know that they are allowed to file a complaint. It would be unusual if more than a small percentage of a PPO’s members knew that there was an actual process for filing the complaint with the PPO. Consider this. When you walk into any Wal-Mart there are large signs that state if you are not 100% satisfied, you will get a full refund. That message is a major part of their advertising. A PPO takes the opposite approach. Instead of aggressively looking for ways to improve, it hides its complaint process in the thick document patients are given explaining their policies.

Statute excerpts

Ins 3.48 Preferred Provider plans.

(1) SCOPE. This section applies to all preferred provider plans as defined in s. 609.01 (4), Stats.

(2) DEFINITIONS. In this section:

(a) “Complaint” means any dissatisfaction about an insurer or its contracted providers expressed by an enrollee.

(b) “Grievance” means any dissatisfaction with the administration or claims practices of or provision of services by a preferred provider plan which is expressed in writing by or on behalf of a plan enrollee.

(3) EXCESSIVE DISTANCES.

(a) Except as provided in pars. (b) and (c), preferred provider plans shall offer coverage to a person only if preferred providers of primary care services and emergency services are available within 30 minutes’ travel time of the person’s place of residence.

(b) A preferred provider plan may offer coverage on a group basis to an employer for its employees or to an employe organization without taking into account the places of residence of the employees, if preferred providers of primary care services and emergency services are available either within the county or within 30 minutes’ travel time of the employment location.

(c) A preferred provider plan may provide coverage to a person without taking into account the person’s place of residence or employment if the person is informed in writing of the services covered and the location of all preferred providers and makes a written request for coverage.

(4) CONTINUITY OF PATIENT CARE.

(a) Subject to pars. (b), (c), (d) and (e), a preferred provider plan which is offered on a group basis to an employer for its employees or to an employe organization shall extend enrollment periods for group members and their families who wish to be enrolled in the plan, but who are in a course of treatment with a provider not selected by the plan and wish to continue that course of treatment. Enrollment standards for those who request an extended enrollment period shall be no more restrictive than they are for those who enroll during the normal enrollment period.

(b) A preferred provider plan may require a group member to request an extended enrollment period during the normal enrollment period specified by the plan and to indicate the nature and the expected duration of the course of treatment.

(c) A preferred provider plan is not required to extend enrollment opportunities to a dependent of a group member unless the group member and any other dependents also receive an extension.

(d) A preferred provider plan may limit the extension of the enrollment period for a group member and dependents to 90 days after the effective date of the contract.

(e) A preferred provider plan shall receive no premiums and bear no responsibility for coverage of group members and their dependents until they are enrolled.

(f) When a person changes from one plan to another, the responsibilities of the prior and succeeding insurers outlined in s. Ins 6.51 (6), (7) and (8) shall apply.

(5) SUBSTANTIALLY EQUIVALENT BENEFITS BEFINED.

(a) For purposes of s. 609.10 (1) (a), Stats., Plans will be considered to provide substantially equivalent benefits if they offer comparable coverage for the following services: hospital room and board, other inpatient hospital services, surgery, home and office physician services, in hospital physician care, x-ray and laboratory services.

(b) Notwithstanding par. (a), plans providing substantially equivalent benefits may differ as to premium, deductible, coinsurance, benefit maximum provisions and limitations on choice of providers.

(c) Plans providing substantially equivalent benefits may differ in their coverage of services other than those listed in par. (a).

(6) ADEQUATE NOTICE.

(a) Preferred provider plans shall provide to policyholders information on the plan, including information on the services covered; a definition of emergency services if emergency services are covered differently than other services; the specific location of providers for each type of service; the cost of the plan; enrollment procedures; limitations on benefits, including limitations or requirements imposed by an institutional provider because of its affiliation with a religious organization; and restrictions on choice of providers. This information shall be provided to employers at least 30 days before the first day of each enrollment period. The preferred provider plans shall ensure that employers make this information available to all prospective certificate holders in time for them to make an informed choice among available plans. If a preferred provider plan is offered on an individual basis, the information shall be given at the time of application.

(b) The information provided shall be legible, complete, understandable, presented in a meaningful sequence, contain a single section listing exclusions and limitations and define words and expressions which are not commonly understood or whose commonly understood meaning is not intended.

(c) The information provided shall meet the standards for an invitation to apply set forth in s. Ins 3.27.

(7) Grievance Procedure

(a) A preferred provider plan shall investigate each grievance pursuant to s. 609. 15 (2), Stats. Each preferred provider plan shall develop an internal grievance procedure and shall describe the grievance procedure in each policy and certificate issued to enrollees, Policies and certificates shall include a definition of a grievance.

(b) In addition tea the notice requirement under par. (a), each time the preferred provider plan denies a claim or benefit, including a refusal to refer an enrollee, or initiates disenrollment proceedings, the preferred provider plan shall notify the affected enrollee of the right to file a grievance and the procedure to follow. The notification shall state the specific reason for the denial or initiation.

(c) A preferred provider plan shall resolve all grievances within 30 calendar days of receiving the grievance. If the preferred provider plan is unable to resolve the grievance within 30 calendar days, the time period may be extended an additional 30 calendar days if the preferred provider plan notifies, in writing, the person who filed the grievance that the preferred provider plan has not resolved the grievance, when resolution may be expected, and the reason for why additional time is needed.

(d) A grievance procedure shall include a method whereby the enrollee who made the grievance has the right to appear in person before the grievance committee to present written or oral information and to question those people responsible for making the determination which resulted in the grievance. The preferred provider plan shall inform the enrollee in writing of the time and place of the meeting at least 7 calendar days before the meeting.

(e) Pars. (b), (c) and (d) do not apply in urgent care situations. Preferred provider plans shall develop a separate grievance procedure, for urgent cars; situations. This procedure shall require a preferred provider plan to resolve an urgent care situation grievance within 4 business days of receiving the grievance.

(f) Preferred provider plans shall record, retain, and report records for each complaint and grievance in accordance with all of the following requirements:

1. Each preferred provider plan shall keep and retain for at least a three-year period a record for each complaint and grievance submitted to the preferred provider plan.

2. Each provider contract and administrative services agreement entered into between a preferred provider plan and a provider shall contain a provision under which the provider must identify complaints and grievances and forward these complaints and grievances in a timely manner to the preferred provider plan for recording and resolution.