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The American Journal of Managed Care March 2018
False-Positive Mammography and Its Association With Health Service Use
Christine M. Gunn, PhD; Barbara Bokhour, PhD; Tracy A. Battaglia, MD, MPH; Rebecca A. Silliman, MD, PhD; and Amresh Hanchate, PhD
Incorporating Value Into Physician Payment and Patient Cost Sharing
Zirui Song, MD, PhD; Amol S. Navathe, MD, PhD; Ezekiel J. Emanuel, MD, PhD; and Kevin G. Volpp, MD, PhD
Development and Implementation of an Academic Cancer Therapy Stewardship Program
Amir S. Steinberg, MD; Anish B. Parikh, MD; Sara Kim, PharmD; Damaris Peralta-Hernandez, RPh; Talaat Aggour, BPharm; and Luis Isola, MD
Overuse and Insurance Plan Type in a Privately Insured Population
Meredith B. Rosenthal, PhD; Carrie H. Colla, PhD; Nancy E. Morden, MD; Thomas D. Sequist, MD; Alexander J. Mainor, JD; Zhonghe Li, MS; and Kevin H. Nguyen, MS
Patients Discharged From the Emergency Department After Referral for Hospitalist Admission
Christopher A. Caulfield, MD; John Stephens, MD; Zarina Sharalaya, MD; Jeffrey P. Laux, PhD; Carlton Moore, MD, MS; Daniel E. Jonas, MD, MPH; and Edmund A. Liles Jr, MD
Trends in Opioid and Nonsteroidal Anti-Inflammatory Use and Adverse Events
Veronica Fassio, PharmD; Sherrie L. Aspinall, PharmD, MSc; Xinhua Zhao, PhD; Donald R. Miller, ScD; Jasvinder A. Singh, MD, MPH; Chester B. Good, MD, MPH; and Francesca E. Cunningham, PharmD
Ambulatory Care–Sensitive Emergency Visits Among Patients With Medical Home Access
Dina Hafez, MD; Laurence F. McMahon Jr, MD, MPH; Linda Balogh, MD; Floyd John Brinley III, MD; John Crump, MD; Mark Ealovega, MD; Audrey Fan, MD; Yeong Kwok, MD; Kristen Krieger, MD; Thomas O'Connor, MD; Elisa Ostafin, MD; Heidi Reichert, MA; and Jennifer Meddings, MD, MSc
Improving Quality of Care in Oncology Through Healthcare Payment Reform
Lonnie Wen, RPh, PhD; Christine Divers, PhD; Melissa Lingohr-Smith, PhD; Jay Lin, PhD, MBA; and Scott Ramsey, MD, PhD
Assessing Medical Home Mechanisms: Certification, Asthma Education, and Outcomes
Nathan D. Shippee, PhD; Michael Finch, PhD; and Douglas R. Wholey, PhD
Currently Reading
Patient-Reported Denials, Appeals, and Complaints: Associations With Overall Plan Ratings
Denise D. Quigley, PhD; Amelia M. Haviland, PhD; Jacob W. Dembosky, MPM; David J. Klein, MS; and Marc N. Elliott, PhD

Patient-Reported Denials, Appeals, and Complaints: Associations With Overall Plan Ratings

Denise D. Quigley, PhD; Amelia M. Haviland, PhD; Jacob W. Dembosky, MPM; David J. Klein, MS; and Marc N. Elliott, PhD
Patient ratings of plans and care were lower among beneficiaries filing complaints or reporting denied care. Appeals did not further predict ratings, but successful complaint resolution did.

Objectives: To assess whether Medicare patients’ reports of denied care, appeals/complaints, and satisfactory resolution were associated with ratings of their health plan or care.

Study Design: Retrospective analysis of 2010 Medicare Advantage Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data.

Methods: Multivariate linear regression of data from 154,766 respondents (61.1% response rate) tested the association of beneficiary ratings of plan and care with beneficiary reports of denied care, appeals, complaints, and complaint resolution, adjusting for beneficiary demographics.

Results: Beneficiaries who reported being denied needed care rated their plans and care significantly less positively, by 17.2 points (on a 100-point scale) and 9.1 points, respectively. Filing an appeal was not statistically significantly associated with further lower ratings. Beneficiaries who filed a complaint that was satisfactorily resolved gave slightly lower ratings of plans (–3.4 points) and care (–2.5 points) than those not filing a complaint (<.001 for all results).

Conclusions: Lower ratings from patients reporting complaints and denied care may notably affect the overall 0-10 CAHPS ratings of Medicare Advantage plans. Our results suggest that beneficiaries may attribute the actions that lead to complaints or denials to plans more than to the care they received. Successful complaint resolution and utilization management review might eliminate most deficits associated with complaints and denied care, consistent with the service recovery paradox. High rates of complaints and denied care might identify areas that need improved utilization management review, customer service, and quality improvement. Among those reporting being denied care, filing an appeal was not associated with lower patient ratings of plan or care.

Am J Manag Care. 2018;24(3):e86-e92
Takeaway Points
  • Patients who reported denials of needed care gave low ratings to their care, and especially their plan, regardless of whether they appealed the denial. Beneficiaries satisfied with complaint resolution provided only slightly lower ratings than those with no complaints.
  • Medicare beneficiaries may largely attribute the actions that lead to complaints or denials to their plans more than to the care they received.
  • Medicare plans should focus on successful complaint resolution, as it can substantially mitigate the low ratings patients give their plan that result from whatever motivated them to file a complaint.
Patients’ complaints about their health insurance plan and denials of care are important aspects of the patient experience. The extent to which specific care is necessary can be complex and contentious.1,2 Denials to cover care may reflect barriers to accessing needed care or appropriate curtailing of unnecessary care. Throughout this article, we will refer to a health plan’s decision to not cover care as “denial of care” as an imperfect shorthand for the patient’s report, recognizing that patients can choose to pay out-of-pocket or out-of-network for their care. Similarly, complaints about health insurance plans may indicate a misunderstanding, a lack of plan responsiveness, or appropriate voicing of patient concerns.

Managed care organizations have delivery systems that greatly influence interactions between physicians and patients.3-6 Their rules and restrictions on choice of providers, network coverage, review processes, preauthorization, and drug formularies may create conflicts with patients and providers. Through the denial and appeals process, patients, physicians, and health plans communicate and determine what care is medically necessary.

As required by CMS, all Medicare Advantage (MA) contracts (health plans) must provide beneficiaries a means to file a complaint or appeal a denial of coverage.7 Denied coverage for care may adversely affect MA enrollees’ perceptions of plans and care. Nineteen percent of 2010 Medicare beneficiary disenrollments were prompted by denials of coverage for medical services,8 and over one-third of callers to the Medicare Rights Center’s national helpline expressed difficulty managing coverage denials and appeals.9

Health plans may benefit from how they respond to grievances, complaints, and service failures, known as service recovery.10 Bitner et al11 found that it is not the service failure that reduces customer ratings of their plan or care, but the service provider’s actions (ie, recovery) following the failure that matter. This phenomenon is the “service recovery paradox,” wherein those who complain and see their problems resolved by the offending organization may rate the organization higher than those who experience no problems.12-14

Service recovery in healthcare differs from other settings, like retail, banking, restaurants, or hotels, because it may not be possible to “make things right” or “undo the situation” in healthcare. A service provider’s apology also could be construed as an admission of a mistake and become the basis for litigation.15 The few articles about healthcare service recovery in the literature primarily offer managerial suggestions to healthcare administrators rather than empirical evidence.16-19 One study of a single health management organization (HMO) found a strong positive relationship between satisfaction with the complaint handling process and overall satisfaction with the HMO.20

In general, however, relatively little is known about how denials of coverage for needed care, subsequent appeals of the denied coverage or complaints, and resolution status affect a patient’s rating of their plan or care. The question remains whether patients attribute the denial or complaint to their plan or to their providers. These attributions may also differ by beneficiaries’ health status, given that a denial of care may have greater consequences for those in poor health or with multiple chronic conditions.

Previous research on patient complaints and plans’ reported denials of care has focused on whether a patient has negative or positive experiences with care coverage and identifying any contributing factors. For example, kidney transplant recipients’ interactions with their insurers21 suggest that patients have difficult interactions with insurers and limited skills in navigating insurance options, thereby curbing their access to needed medications and health services. More than one-third of Medicaid enrollees reported denials of care for their children in the previous year, with families of children with chronic conditions more likely to report a denial of care.22

Among the few studies that have focused on patient complaints and plans’ reported denials of care, only 2 appear to examine the relationship between denial of care (whether it was appealed and its resolution) and the patient’s subsequent rating of their health plan or care. Denial of needed care was associated with lower ratings of health plan quality and significantly less trust in patients’ primary care physicians.23 Similarly, many patients who are denied authorization for emergency department (ED) care are dissatisfied with their health plan but still intend to return to the ED.24 These results follow Folger’s fairness theory,25-28 which states that judgments of fairness are related to people’s “would/could/should” reasoning about a decision by a powerful other. Fairness theory predicts that after being denied care, the patient, in assigning responsibility for the injustice, would choose the powerful other with the most “could” authority, here the health plan with authority over authorizations, not the care provider.

This article uses a nationally representative sample of MA enrollees to assess the relationship between patient-reported denials of care, appeals, complaints, and resolution and their association with overall patient ratings of plans and care. Information on plan disenrollment or health plan ratings prompted by coverage denials could be a valuable tool for consumers who need to select a plan or identify an important missed opportunity for Medicare and other health plans for service recovery with patients. Furthering understanding of complaints and reported denials of care is especially pertinent for Medicare recipients, whose average healthcare needs exceed those of the general population and who, in some cases, may have difficulty managing the complaint or appeal process due to age or infirmity.

In 2010, the MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey provided a unique opportunity to study these issues, as it included items that asked about complaints and denial of care. Under the Affordable Care Act, patient experience measures from this survey play a role in the determination of quality bonus payments for MA plans.29

This study used additional items from the 2010 MA CAHPS survey to assess the association of MA enrollee ratings of their plan and care with whether they reported a denial of needed care, appealed the denial, or filed a complaint, along with the resolution status of the complaint. We first established the extent to which MA beneficiaries reported filing complaints with their plans or being denied coverage for needed care. Then we tested whether those with complaints/denials provided lower ratings of their health plan or care. Based on fairness theory, we hypothesized that members would assign less blame to the care they received because caregivers did not have the power  (ie, “could” authority) to accept or deny the appeal. In contrast, health plan management did have the “could” authority, and so responsibility was attributed to health plans. Thus, plans received lower ratings. Next, we tested whether the patient ratings of their plan and care differed for those filing an appeal and those with successful resolution of an appeal. Based on the service recovery paradox, we hypothesized that members with successful resolution would rate their health plan nearly as high or even higher than those who experienced no problems. Finally, we tested whether those who are in poorer health rated their plans or care more negatively following denied coverage or complaints.


We used data from the 2010 MA CAHPS survey, which included items on complaints and denial of care. This survey was a mail survey of MA beneficiaries, with telephone follow-up on nonrespondents.

Our population of interest was MA enrollees 65 years or older, excluding those in US territories. The analysis was restricted to responding beneficiaries (61.1% response rate for this population), excluding the 6% not completing items about complaints or denial of care, which left 154,766 cases. We examined responses to the survey items listed in Table 1 and estimated health contract–level standard deviations of denial, appeal, complaint, and resolution responses as the square root of contract variance components.

Second, multivariate linear regression predicted the responses to 2 ratings (health plan and care) from the denial, appeal, complaint, and resolution responses and several covariates: gender, age, race/ethnicity, education, self-reported health and mental health status, Census division, self-reported chronic conditions, Patient Health Questionnaire-2 depression symptoms,30 current smoking status, functional limitations, proxy assistance, dual eligibility for Medicaid, Part D or MA only, Special Needs Plan status, and whether the respondent had a personal doctor. We ran 4 sets of regression analyses to calculate 1) population estimates, 2) within-contract estimates, 3) associations, and 4) differences in these associations. Data were weighted to account for the sample design and nonresponse.

An additional model (results not shown) assessed whether those with poorer health had a stronger negative association with plan ratings than those in better health via an interaction term between overall health status and denial of service. As the average associations were similar for those who did and did not subsequently file an appeal of the denied care, we combined these groups in this analysis.


Characteristics of the Sample

Characteristics of the MA beneficiaries 65 years and older appear in Table 2 [part A and part B]. Forty-three percent were male, 72% were non-Hispanic white, and 26% were 80 years or older. Eighteen percent had a 4-year college degree, and 14% did not have Part D coverage through their MA plan.

Prevalence of Denials, Appeals, and Complaints

Table 3 shows the prevalence of denials, appeals, and complaints. Six percent of respondents reported that their plan denied care or services they believed they needed. Among beneficiaries who reported a denial of needed care or services, 49% filed an appeal. Overall, 8% of respondents filed a complaint, 54% of whom indicated that their complaint was resolved to their satisfaction.

The contract-level standard deviation of satisfactory complaint resolution from a linear mixed model was 9.9%, suggesting that approximately two-thirds of health plans had rates of satisfactory complaint resolution between 44% and 64% (after accounting for sampling error) and that most contracts had a rate of satisfactory complaint resolution ranging from 34% to 74%. Complaints, which had a contract-level standard deviation of 3.8%, involved a variety of issues and did not necessarily concern denials of needed care. Contract-level standard deviations were 3.7% for reports of denial of care and 5.4% for appeals.

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