Annual patient protection reports
Effective in 1998, Oregon adopted the "Patient Protection Act," which establishes broader consumer protection in the areas of disclosure to consumers, grievance procedures, emergency room claims, and prior authorizations.
It also requires annual reporting in four areas: grievance statistics, utilization review procedures, quality assessment summaries, and scope of network summaries.
Exempt from reporting
Companies not domiciled in Oregon with less than $2 million in premium are not required to report.
Description of patient protection reports
Grievance report: Health insurers in Oregon must file an annual report on their ability
to promptly resolve consumer complaints. The report identifies a number of grievance
categories, reports how many decisions are upheld or reversed, and at what level
of appeal those complaints are resolved.
Utilization review: Those insurers that require pre-authorization for treatment are
required to file an annual summary relating to the insurer's utilization
review policies. The report includes information on how utilization decisions
are made, the timeliness of completing reviews, and how utilization review criteria
is developed and revised. Supplemental reports, including work plans, evaluations,
and review statistics, may also be included with their reporting
Network adequacy: Managed care organizations must file an annual report on the
scope and adequacy of their provider network. The report includes the insurer's
ongoing monitoring that all covered services are reasonably accessible to enrollees.
Quality assessment: Managed care organizations must file an annual quality assessment
report on their ability to identify and achieve relevant quality improvement
goals. This allows insurers to evaluate, maintain, and improve the quality of
health services provided to enrollees. Insurers may provide supplemental reports
related to their quality assessment review, including their goals, work plans,