Resolution timeliness and appropriateness of the complaints closure process by Medicare Part C and D sponsors

Currently, CMS routinely monitors whether plan sponsors meet required timeframes for closing beneficiary complaints. Sponsors are accountable for the prompt resolution of complaints. However, there is not a monitoring mechanism or measure of the process sponsors use to close complaints and the appropriateness of the resolution. This is an important area for CMS oversight given that in the first half of CY2008 there were 135,330 complaints (primarily about pricing/Coinsurance and enrollment/disenrollment).

In this paper, we present the results of a CMS study funded to develop and implement four measures to assess the appropriateness of complaints closure. Three measures address actual resolution timeliness and whether there is a resolution, and a fourth measure addresses the “correctness” of the plan's resolution. These measures were calculated for representative samples of the universe of complaints. Data came from the HPMS CTM module and a web-based instrument for 99% of all Part C and D contracts in CY2009. Results indicate that on average contracts “closed” 6.45% of their complaints before identifying a resolution and about 15% before implementing a resolution. In both instances, MAPDs were more likely than MA-only and PDPs to close complaints in the CTM prior to identifying a resolution and there are significant differences in organization type (RCCP vs PFFS). The qualitative data provided by contracts indicates that 84% of complaints were “correctly” resolved by contracts. Thus, there is still room for improvement in the complaints resolution process.