President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry

Consumer Bill of Rights and Responsibilities
Chapter Seven
Complaints and Appeals

Statement of the Right All consumers have the right to a fair and efficient process for resolving differences with their health plans, health care providers, and the institutions that serve them, including a rigorous system of internal review and an independent system of external review.

Internal appeals systems should include:

External appeals systems should:


Health care consumers, like other purchasers, have concerns about the service they receive. Unlike other consumers, however, health care consumers have special interests at stake -- the length and quality of their lives. How consumer complaints are addressed has a significant impact on the quality of health services provided and on the satisfaction of consumers with the individuals and institutions that provide them.

Fair and efficient procedures for resolving consumer complaints about their health care serve many purposes. First and foremost, enhanced internal and external review processes will assist consumers in obtaining access to appropriate services in a timely fashion, thus maximizing the likelihood of positive health outcomes. Second, they can be used to bridge communication gaps between consumers and their health plans and providers, and to provide useful information to all parties regarding effective treatment and consumer needs. Third, the opportunity for consumers to be heard by people whose decisions significantly touch their lives evidences respect for the dignity of consumers as individuals and engenders their respect for the integrity of the institutions that serve them.

Properly structured complaint resolution processes should promote the resolution of consumer concerns as well as support and enhance the overall goal of improving the quality of health care. Internal and external complaint and appeal processes should be:

Internal and external complaint and appeal processes should not interfere with communication between consumers and their health care providers. For example, in instances where consumers and their providers agree that a service should be reduced or terminated, no written notification of such decisions is needed. Additionally, health care providers who participate in the complaint and appeal processes on behalf of patients should be free from discrimination or retaliation. Likewise, consumers who file a complaint against a provider or plan should be free from discrimination or retaliation.

For the purposes of this chapter, the following definitions are used for the terms "complaints" and "appeals":

Current Resolution Processes

Currently, many different procedures are used by group purchasers, health plans, and provider organizations to respond to consumer complaints. Licensed health plans are subject to numerous State and Federal laws, and many also comply with the standards of private accrediting bodies (e.g., NCQA, 1997; JCAHO, 1996; AAHCC/URAC, 1996). Virtually all private and public health plans provide consumers with some form of complaint resolution process. The Commission does not intend by these recommendations to weaken existing consumer protections. These include:

Implications of the Right

Assuring that all consumers have access to both internal and external processes that satisfy the requirements of this right will require action on virtually every level of the health care industry.

References and Selected Reading

Abraham KS. Insurance Law and Regulation 92-139; 1990.

American Accreditation Health Care Commission/Utilization Review Accreditation Commission (AAHCC/URAC). National Network Accreditation Standards. Washington, DC; April 1996.

American Association of Health Plans. Health Plans Announce Policies on Appeals Rights and Emergency Care Coverage. Washington, DC; January 1997.

American Bar Association, Commission on Legal Problems of the Elderly, Roundtable on the Resolution of Consumer Disputes in Managed Care. Washington, DC; 1997.

American Hospital Association: State Issues Forum. Designing Consumer Protection Standards. Chicago; 1996.

American Psychiatric Association. Principles for the Provision of Mental Health and Substance Abuse Treatment Service: A Bill of Rights. Washington, DC; 1997.

Atkins G, Bass L and K. ERISA Preemption: The Key to Market Innovation in Health Care. New York: Corporate Health Care Coalition; 1995.

Butler P, Polzer K. Private Sector Health Coverage: Variation in Consumer Protections under ERISA and State Law. Washington, DC: National Health Policy Forum, George Washington University; June 1996.

Citizen Action. Campaign for Health Security Managed Care Principles. Washington, DC; January 1997.

Committee on Choice and Managed Care. Assuring Public Accountability and Information, Improving the Medicare Market: Adding Choice and Protections. Washington, DC: Institute of Medicine; 1996.

Dame L, Wolfe SM. Serious Problems for Older Americans in Health Maintenance Organizations. Public Citizen's Health Research Group; May 1995.

Families USA. HMO Consumers at Risk: States to the Rescue. Washington, DC; 1996. Update March 1997.

Joint Commission on Accreditation of Healthcare Organizations, 1996. Accreditation Manual for Hospitals. Chicago; 1996.

Kinney ED. "Resolving Grievances in a Managed Care Environment." Health Matrix 1996 winter; 6:147-165.

Kinney ED. "Protecting Consumers and Providers under Health Reform: An Overview of the Major Administrative Law Issues." Health Matrix 1995; 5:83-138.

Medicare Rights Center. Medicare Appeals and Grievances: Strategies for System Simplification and Informal Consumer Decisionmaking. New York; 1996.

National Association of Insurance Commissioners (NAIC). Health Carriers Grievance Procedure Model Act. October 1996.

National Committee on Quality Assurance (NCQA). "Standards for Members' Rights and Responsibilities." Surveyor Guidelines; April 1, 1997.

Physician Payment Review Commission. Annual Report to Congress 1997. Washington, DC; 1997.

Public Policy and Information Fund of New York. The Managed Care Consumers' Bill of Rights. New York; October 1995.

Richardson DA, Phillips J, Conley D Jr. A Study of Coverage Denial Disputes between Medicare Beneficiaries and HMOs. Pittsford (NY): Center for Health Dispute Resolution, Network Design Group, Inc.; September 1993.

Rodwin MA. "Managed Care and Consumer Protection: What are the Issues?" Seton Hall Law Review Winter 1996; 26:1007-1054.

Stayn SJ. "Securing Access to Care in Health Maintenance Organizations: Toward a Uniform Model of Grievance and Appeals Procedures." Columbia Law Review June 1994; 94:1674-1720.

  1. The right to external appeals does not apply to denials, reductions, or terminations of coverage or denials of payment for services that are specifically excluded from the consumer's coverage as established by contract.
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Last Revised: Friday, July 17, 1998