Managed Care: Recent Proposals for New Grievance and Appeals Procedures (CRS Report for Congress)
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| Release Date |
March 1, 1999 |
| Report Number |
RL30077 |
| Report Type |
Report |
| Authors |
Jon O. Shimabukuro, American Law Division |
| Source Agency |
Congressional Research Service |
Summary:
Because managed care is premised on notions of cost and the ability to control the utilization of
health care services, many fear that decisions involving access to treatment and reimbursement are
made improperly; that the cost of treatment plays an increasingly important role in the decision-
making process. Concern over decision-making and treatment costs has prompted greater attention
to the rights of participants to appeal denials of treatment and to file grievances about other plan
decisions. Some believe that improved grievance and appeal rights would not only empower
patients, but enhance access to treatment and improve the quality of care provided. Others, including
the managed care industry, contend that new requirements are likely to disrupt existing appeals
systems that already work well.
As the 106th Congress considers enacting legislation for improved grievance and appeals
procedures, it may review various recent proposals for guidance. This report will discuss the work
of the President's Advisory Commission on Consumer Protection and Quality in the Health Care
Industry, legislative proposals, and proposed regulations of the Department of Labor.
