Increasing Consumer Power in the Grievance and Appeal Process for Medicare HMO Enrollees

Federal law requires that Health Maintenance Organizations (HMOs) and Managed Care Organizations (MCOs) provide Medicare beneficiaries with specific grievance and appeal rights for challenging adverse decisions of these organizations. The Health Care Financing Administration (HCFA) is charged with enforcing these regulations. Currently, however, HCFA contracts with HMOs, allowing them to enroll Medicare beneficiaries despite the fact that many of the statutory and regulatory requirements are ignored by the Medicare HMOs. This is problematic because the elderly Medicare population may not be able to independently and adequately challenge the HMO’s denial of care or reimbursement. Because HCFA has been reluctant and ineffective in ensuring that Medicare enrollees are guaranteed grievance and appeal rights, other alternatives should be explored. This Note argues that private accreditation, for those Medicare HMOs that choose to be subjected to the process, should be allowed as an alternative to regulation under HCFA.