Texas Department of Insurance Life, Health, and Licensing Compliance Workshop October 31, 2006

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Texas Department of InsuranceLife, Health, and
Licensing Compliance WorkshopOctober 31, 2006

• TDI Complaint Process
• Valerie Brown, CPCU Director
• Complaints Resolution
• Patricia Brewer - Director
• HWCN Special Projects

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Inquiry vs. Complaint

• A request for insurance information from an
  external customer received during business hours
• Customers include
• individual insurance consumers
• business consumers
• regulated entities
• state agencies
• legislators

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What is a Complaint?
Any dissatisfaction expressed by a
complainant orally or in writing to the health
maintenance organizations operation, including
but not limited to dissatisfaction with plan
administration procedure related to review or
appeal of an adverse determination, as that term
is defined by Section 843.261, the denial,
reduction, or termination of a service for
reasons not related to medical necessity, the way
a service is provided or disenrollment
decisions, expressed by a complainant. The term
does not include a misunderstanding or a problem
of misinformation that is resolved promptly by
clearing up the misunderstanding or supplying the
appropriate information to the satisfaction of
the enrollee and does not include a providers or
enrollees oral or written dissatisfaction or
disagreement with an adverse determination. T
IC 843.002(6)
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TDI Complaint Process

• Consumer Protection - PPO/Indemnity
• HWCN Quality Assurance Section HMO,URA, IRO,
  WCHCN
• Complaints are received at TDI via
• Regular, certified, overnight mail
• Fax
• Walk-in consumer
• E-mail
• On-line complaint form
• Complaints are sorted by product (PPO, HMO)
• Input into TDI Complaint Inquiry System (CIS)
• Acknowledgment letter sent to complainant

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• Inquiry letter to company requesting specific
  information on complaint
• Confirmation on type of coverage
• Evidence of Coverage regarding issue
• Correspondence exchanged
• Claim information
• Carriers have 10 days to respond to TDI
  inquiries, per Texas Insurance Code Section
  38.001
• Response is received from carrier and matched to
  the complaint
• Response is reviewed by an insurance specialist
  or registered nurse
• Is the response sufficient in depth and scope?
• Can the complaint be resolved?
• Additional information requested, if needed

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• Complaint closed
• Closing correspondence to complainant with copy
  of company response
• Copy of closing correspondence to company and/or
  agent
• Complaint closed in CIS
• Is complaint justified or unjustified?
• Should complaint be referred to Enforcement?
• Complaints can be reopened with additional
  information and/or continued violation of rule or
  statute

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All LAH Complaints ClosedFiscal Year 2006Total
Closed 13,518
Note Complaints may be coded for more than one
category, therefore, percentages may total gt 100
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Provider PPO ComplaintsFY 2006Total Closed
1,398
Note Complaints may be coded for more than one
category, therefore, percentages may total gt 100
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LAH Complaints Annual WorkloadFY 2006

• Total number of complaints received
  16,144
• Total number of complaints closed
  13,518
• Total number of complaints justified
  1,677
• Average number of days to resolve complaint
  33.00
• Monies recovered for consumers
  15.1 million

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All HMO Complaints Closed Fiscal Year 2006Total
Closed 2053
Note Complaints may be coded for more than one
category therefore, percentages may total gt100
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Total Provider HMO Complaints ClosedFY
2006Total Closed 1197
Note Complaints may be coded for more than one
category therefore, percentages may total gt100
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HWCN Annual WorkloadFY 2006

• Total number of complaints received 2,063
• (Includes 17 WC Network complaints)
• Total number of complaints closed 2,053
• Total number of complaints justified 489
• Average number of days to resolve complaint
  35
• Record only complaints 605
• Included in closed complaints

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What Makes a Complaint Justified?

• An apparent violation of a policy provision,
  contract provision, rule or statute
• A valid concern that a prudent layperson would
  regard as a practice or service that is below
  customary business or medical practice

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Examples of Justified Complaints

• Claim was denied when it should have been paid
• Claim was not paid within 45 days
• Penalty was not paid when claim was paid late or
  incorrectly
• Policy was not cancelled according to contract
  provisions, rules or statutes
• Complaint and appeal or utilization review
  timelines were not followed
• Untimely responses to TDI

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Preventing Complaints to TDI

• Assure customer service, provider relations, and
  claims staff are well informed and communicate
  effectively
• Maintain adequate staff to respond to members and
  providers
• Monitor call times
• Respond to complaints within 30 days
• Meet with provider groups to resolve managed care
  issues
• Pay, deny, or audit claims per the Clean Claim
  Rules

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Insurers Response to TDI

• Maintain a complaint log (record)
• Respond in 10 days
• Use document ID throughout correspondence
• Provide extension request in writing per
  Commissioners Bulletin B-0040-00
• Send final response to TDI one time
• via email
• via fax
• direct response to appropriate TDI area or staff
  member
• Forward or return misdirected complaints

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FAQs

• What needs to be included in the response for a
  claims complaint?
• What needs to be included in the response for a
  quality of care complaint?
• Are complaint logs (records) mandatory?
• Where can I find the mandatory requirements
  regarding HMO complaints/complaint system?

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Complaint Web Data

• TDI maintains information regarding complaints in
  a computerized tracking system (CIS)
• Selected information from CIS is included in the
  Internet Complaint Information System (ICIS)
• Information included in ICIS is not the entire
  universe of available complaint information
• Other information regarding complaints may be
  obtained under the Texas Public Information Act.
• Categories of complaint information
• Those most often requested
• The type of information generally considered most
  useful
• ICIS contains only closed complaints
• Information in ICIS will be updated at least
  quarterly
• If a closed complaint is reopened, the complaint
  will be removed when ICIS is updated and will
  reappear on the next update after the complaint
  is reclosed.

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What to Expect From ICIS

• Most TDI closed complaints by quarter
• More than 55,000 auto, home, health, and other
  insurance-related complaints
• 15 categories of data from company name to type
  of complaint
• Requirements
• A spreadsheet or database program to view files
• A computer hard drive, NOT a floppy disk for
  saving files

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Resources

• Website
• www.tdi.state.tx.us
• Toll Free Information
• 1-800-252-3439
• Valerie Brown (Consumer Protection)
• 512/463-6503
• Debra Diaz-Lara, Pat Brewer (HWCN Division)
• 512/322-4266