Complaints

In what some veteran reviewers might see as a change in interpretation, it appears that URAC is now including employees in what has previously been seen as a standard designed to protect only consumers.

Core 27 reads:

"The organization maintains a system to receive and respond in a timely manner to complaints and, when appropriate, inform consumers of their rights to submit an appeal."

Historically, URAC reviewers have read this as referring to consumers, which URAC defines as "An individual person who is the direct or indirect recipient of he services of the organization. Depending on the context,consumers may be identified by different names, such as "member,” enrollee,” “beneficiary,” “patient,” “injured worker,”“claimant,” etc."

Note, however, that "employee" isn't one of the suggested synonyms for "consumer."

So, imagine my surprise when I learned that at least one URAC reviewer is now reading this standard more broadly, saying that, despite the fact that an applicant is describing its member and client appeals system thoroughly enough, its submission is insufficient, in that it does not explain how employees and the community (including "office neighbors, parking or grounds attendants") can file a complaint.

Let there be no mistake -- this is no complaint. I have nothing vested in a particular interpretation of a URAC standard. If URAC wants to expand the scope of this standard to include employees and community members, more power to it. I provide this here simply to alert our readers that their submission for this standard is likely to be insufficient if it includes only a description of its complaints and appeals system for consumers and clients.

One set of URAC's Core standards, Core 27-29, spell out requirements for complaints and appeals. They provide:

CORE - 26 - Complaint and Appeal System
The organization maintains a system to receive and respond in a timely manner to complaints and, when appropriate, inform consumers of their rights to submit an appeal.
CORE - 27 - Appeal Process
The organization maintains a formal appeal resolution process that includes:
(a) Written notice of final determination with an explanation of the reason for the determination;
(b) Notification of the process for seeking further review, if available; and
(c) A reasonable, specified time frame for resolution and response.
CORE - 28 - Complaint and Appeal Reporting
The organization reports analysis of the complaints and appeals to the quality management committee.

The question I get most often from my clients about these standards is this: "Does this create appeal rights for all complaints?"

The answer is, "no". The standards are careful to use the phrases "if available" and "when appropriate" when referring to appeal rights. Other URAC standards do grant very specific appeal rights, but not these.

No, these standards simply explain that you must have a system for responding promptly to all complaints, and where you do offer appeal rights, that it be formal, including written notice of final determination, notification of the process for appeal, and reasonable time for resolution. And, don't forget to report periodically to the quality committee!

If you say you have no complaints, URAC's view, articulated at a recent education seminar, is that your employees probably don't know what a complaint is.  URAC's definition is broad: "An expression of dissatisfaction regarding the organization’s products or services."  With a definition that broad, URAC's thinking goes, you should have some complaints in your tracking system.