About the Complaint Data Reports
The Office of the Patient Advocate is tasked with producing an annual report on health care complaint data and other consumer assistance information. View the related reporting requirements outlined in California Health and Safety Code Section 136000.
Data Collection and Analysis
For the annual reports, OPA collects and analyzes descriptive information about the state's health care consumer assistance as well as quantitative records on complaints closed during a calendar year. Four state reporting entities - the Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), California Department of Insurance (CDI), and Covered California - are statutorily required to submit non-aggregated complaint data to OPA.
OPA uses standard data practices to analyze and report the data. OPA takes into account privacy concerns and HIPAA restrictions when determining what data is publicly reported. For example for the Baseline Report, OPA did not publicly report data for counties where a small population size and low complaint numbers could mean that individuals could inadvertently be identified.
In order to provide a more equitable comparison of large versus small health plans, OPA calculates and reports complaint ratios based on complaint and enrollment data for each health plan during the measurement year. The enrollment figures are provided by the reporting entities as reported to them by the health plans and insurance companies. The complaint ratio is calculated by taking the number of closed complaints and dividing it by the number of covered lives the health plan had in place by the end of a specific month in the measurement year. OPA standardizes the complaint ratio displays as complaints per 10,000 members.
About the Baseline Report
OPA released its Baseline Report in 2016 based on complaints closed during measurement year 2014. The type of complaint records that were submitted for this first-time-ever report were:
- DMHC - Standard Complaints, Independent Medical Reviews, Quick Resolutions, and Urgent Nurse Complaints
- DHCS - State Fair Hearings [conducted by the California Department of Social Services (CDSS)]
- CDI - Standard Complaints and Independent Medical Reviews
- Covered California - State Fair Hearings (conducted by CDSS)
Complaint Data Definitions
OPA is dedicated to standardizing complaint reporting. Many of terms used in the complaint data reports are based on a national standard, from complaint categories defined by the National Association of Insurance Commissioners. OPA worked with the state reporting entities to map their complaints to standardized categories. Additional terms that are state or entity-specific reporting categories were added as needed.
OPA relied on two primary data distinctions for reporting on consumer assistance cases.
- Complaint: Includes written or oral complaints, grievances, appeals, independent medical reviews, hearings, and similar processes to resolve a consumer problem or dispute.
- Inquiry: A request for assistance when a consumer requires only information on a jurisdictional topic, or education on a non-jurisdictional topic and a referral to another entity.
View the complaint data glossary (PDF).
Other Complaint Data Resources
The following state websites have reports and other information about health care coverage complaints in California.
Department of Managed Health Care
Department of Insurance
Department of Health Care Services
Department of Social Services
The following websites have reports and other information about health care coverage complaints nationally.
National Association of Insurance Commissioners