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Performance oversight and
Reporting–Legal Issues

Whether the performance oversight and reporting relates to Part C or Part D, there are similar legal issues requiring legal advice and consultation. Initially, basic CMS requirements must be satisfied to establish the proper committee and reporting structure, with proper charters for the committees involved, and delineation of responsibilities. Once the basic framework is established in accordance with CMS guidelines, its implementation and operation should normally function without legal advice and consultation.

Certain overriding concerns, however, must be kept in mind. Care must be taken to provide for timely processing of complaints, inquiries, and the like. Even the most easily responded and handled inquiry could result in devastating penalties if mandatory deadlines are missed. Timely input into the response process, and timely referral to the appropriate committee or person assigned to handle the matter, are crucial.

Further, care must be taken to avoid improper classification of data in a fashion which overstates the true level of complaints or reason for disenrollment, because this could result in over-reporting of "complaints" to CMS and State Departments of Insurance which may trigger greater oversight either at the State or Federal level. Furthermore, causing an artificially inflated reporting of "complaints" can be utilized in litigation and claims of bad faith denial of insurance claims to cast the insurer in a bad light before the Jury.

Additionally, unless there is clear delineation of reporting and response duties within the insurance company, the result could very well be a Keystone-Cops drill of a complaint being tossed about from one person to another, treated more like a hot potato than an event that triggers response and reporting duties that will have tightly-dictated time frames for response. While this should normally be a matter to be dealt with through proper personnel decisions and establishing of clear reporting responsibilities, the firm is available if needed to provide general guidance to help the client assure that these duties are clearly delineated. This can be complicated if the insurer utilizes a Third Party Administrator for all or some of the functions. Clear delineation in the contract with the TPA is absolutely critical to avoid both duplication of effort, increasing costs of operation, and dropping certain matters through the cracks, resulting in a failure to deal with these.

There must be clear and reliable tracking of complaints and appeals to avoid failure to meet established time frames for response and handling. The firm can provide guidance to the client in determining the time periods required under both State and Federal requirements for these matters, but, once again, the actual operation of the system should normally function without the input or involvement of outside counsel.

Review of response content is important, to make certain that personnel within the structure do not insert commentary that can be discovered in litigation and utilized as a claimed basis to prove the "bad faith" of the insurer in denying the claim. This can normally be handled through careful and detailed delineation of the operational responsibilities given to the employees throughout the handling process, but, again, if the firm is retained by the insurer to be available for consultation, it can provide guidance on specific cases or groups of issues.