|
The following
information is Michigan HMO Complaint Data for the year 2011. Complaints
can range from a consumer disagreeing with a denial of service to
dissatisfaction with the service they received. An HMO is responsible for
reviewing and responding to all complaints.
Please note that
Medicaid members also have an external complaint process with the Michigan
Department of Community Health (MDCH). This chart does not contain
information from MDCH.
Definitions:
|
Internal
|
|
The first formal
review process conducted by the HMO |
| |
External
|
|
The review
process conducted by OFIR after a consumer has completed the HMOs
internal review process. This process is called the Patients Right
to Independent Review Act (PRIRA). |
| |
Upheld |
|
The decision of
the HMO was upheld by the process. |
| |
Overturned |
|
The decision of
the HMO was overturned by the process. |
| |
Compromise
|
|
A mutually
agreeable decision was reached. |
| |
Resolved |
|
The final
adverse determination was reversed prior to a formal decision by
OFIR. |
| |
Withdrawn |
|
Case removed
from consideration before decision
issued. |
If you have
questions, please contact the Office of Financial and Insurance Regulation
toll free at 877-999-6442
|
| |
|
Total
Level One Determinations* |
|
External PRIRA
Determinations** |
|
Name of HMO |
Upheld |
Overturned |
Compromise |
Total |
Annualized level one complaints
per 1,000 members |
Upheld |
Overturned |
Resolved |
Withdrawn |
Total |
|
Aetna Health,
Inc. |
0 |
0 |
0 |
0 |
0.0 |
0 |
0 |
0 |
0 |
0 |
|
BlueCaid |
3 |
6 |
1 |
10 |
0.5 |
0 |
0 |
0 |
0 |
0 |
|
Blue Care
Network of MI |
1,179 |
883 |
37 |
2,099 |
3.8 |
28 |
3 |
3 |
0 |
34 |
|
CareSource Michigan |
12 |
7 |
374 |
393 |
11.0 |
0 |
0 |
0 |
0 |
0 |
|
Fidelis
SecureCare of MI, Inc. |
11 |
0 |
0 |
11 |
12.9 |
0 |
0 |
0 |
0 |
0 |
|
Grand Valley
Health Plan, Inc. |
5 |
2 |
1 |
8 |
1.0 |
0 |
0 |
0 |
0 |
0 |
|
Health Alliance
Plan of MI |
316 |
507 |
53 |
876 |
2.6 |
1 |
1 |
0 |
0 |
2 |
|
HealthPlus of
MI, Inc. |
30 |
97 |
20 |
147 |
2.0 |
0 |
1 |
0 |
0 |
1 |
|
HealthPlus
Partners |
11 |
17 |
10 |
38 |
0.6 |
0 |
0 |
0 |
0 |
0 |
|
McLaren Health
Plan, Inc. |
120 |
11 |
0 |
131 |
1.4 |
2 |
0 |
3 |
0 |
5 |
Meridian Health Plan of Michigan |
339 |
37 |
0 |
376 |
1.3 |
0 |
5 |
0 |
0 |
5 |
|
Midwest Health
Plan, Inc. |
8 |
0 |
37 |
45 |
0.6 |
0 |
1 |
0 |
0 |
1 |
|
Molina Healthcare |
48 |
52 |
843 |
943 |
4.3 |
0 |
0 |
0 |
0 |
0 |
|
OmniCare Health
Plan |
56 |
1 |
0 |
57 |
1.2 |
0 |
0 |
0 |
1 |
1 |
|
Paramount Care
of MI |
44 |
8 |
32 |
84 |
16.9 |
0 |
0 |
0 |
0 |
0 |
|
Physicians Health Plan |
115 |
48 |
0 |
163 |
4.8 |
5 |
6 |
0 |
0 |
11 |
|
Physicians Health Plan Family
Care |
17 |
11 |
0 |
28 |
1.5 |
1 |
0 |
0 |
0 |
1 |
|
Priority Health
Govt. Programs |
3 |
0 |
0 |
3 |
0.0 |
0 |
0 |
0 |
0 |
0 |
|
Priority Health
Plan |
498 |
43 |
11 |
552 |
1.3 |
15 |
0 |
1 |
0 |
16 |
|
ProCare |
0 |
0 |
0 |
0 |
0.0 |
0 |
0 |
0 |
0 |
0 |
|
Total Health
Care, Inc. |
49 |
4 |
19 |
72 |
1.4 |
0 |
1 |
1 |
0 |
2 |
|
Total Health
Care USA, Inc. |
7 |
0 |
0 |
7 |
0.3 |
0 |
0 |
0 |
0 |
0 |
|
United
Healthcare Community Plan |
57 |
34 |
616 |
707 |
2.9 |
0 |
0 |
7 |
0 |
7 |
|
Upper Peninsula
Health Plan |
1 |
2 |
2 |
5 |
0.2 |
0 |
0 |
0 |
0 |
0 |
|
Year 2011
Total |
2,929 |
1,770 |
2,056 |
6,755 |
2.5 |
52 |
18 |
15 |
1 |
86 |
|
Percent of
Decisions |
43.4% |
26.2% |
30.4% |
|
|
60.5% |
20.9% |
17.4% |
1.2% |
| |