BeneficiaryComplaints   BACK		Medicare Beneficiary Complaints As the Quality Improvement Organization for South Dakota, the South Dakota Foundation for Medical Care is responsible for investigating complaints from Medicare beneficiaries or their representatives. We are responsible for processing complaints involving the quality of care received by the Medicare beneficiary or complaints pertaining to premature discharge from a Medicare provider. Specifically, the Beneficiary Complaint Response Program: Handles complaints from Medicare beneficiaries or their representatives that are initiated in writing or by telephone; Provides a case manager who works with the beneficiary from start to finish to keep the beneficiary informed throughout the review process about the status of their complaint; Utilizes physician peer review to assess clinical quality of care issues in a patient’s record of care (referred to as Medical Record Review); and Focuses on individual-based quality improvement efforts whereby an index case (e.g., an initiating concern) can lead to systems level quality improvements in future care rendered. Some of the typical complaints that beneficiaries file with a QIO may be for issues such as: Received the wrong medication; Underwent inappropriate surgery; Received erroneous dose of medication; Experienced an error in treatment; Received inadequate care or treatment by any healthcare professional; Was discharged too soon; Change in the condition was not treated; Received inadequate discharge instructions. To contact the Beneficiary Complaint Response Program, call 1-800-MEDICARe or our toll free number at (800) 658-2285, or send your written complaint in confidence to South Dakota Foundation for Medical Care 2600 West 49th Street, Suite 300 - P.O. Box 7406 Sioux Falls, SD 57117-7406 You will be directed to an individual who will be able to walk you through the process that follows. Resolving Complaints QIOs have two methods for resolving clinical quality of care beneficiary complaints. The first is through the process of Medical Record Review and the second is through Mediation. When a case is reviewed for quality issues a determination is made: No Substantial Improvement Opportunities are Identified; or Care Could Have Been Better. For cases where “care could have been better,” the reviewer then determines if: Care Was Grossly and Flagrantly Unacceptable; Care Failed to Follow Accepted Guidelines or Usual Practice; Care Could Reasonably Have Been Expected to be Better. Cases falling into either “No Substantial Improvement Opportunities are Identified” or “Care Could Reasonably Have Been Expected to be Better” can then be considered for mediation, and the beneficiary can be contacted to see if there is interest in pursing the mediation option. Cases that are not suitable for mediation are those where “Care Was Grossly and Flagrantly Unacceptable” or where “Care Failed to Follow Accepted Guidelines or Usual Practice.” Medical Record Review Medical record review is the traditional option to resolve a quality of care complaint under Medicare. This is at no cost to the beneficiary. When the QIO receives a written complaint about the quality of services received by a Medicare beneficiary, the QIO will request a copy of the medical record. A doctor of matching specialty will review the medical record. The review process could take three to six months to complete, during which the QIO will keep the complainant informed of the progress of the review. When the review is complete, the QIO notifies the complainant to the final disposition of the complaint. Mediation Mediation is a new option to resolve a quality of care complaint under Medicare. This is at no direct cost to the beneficiary. It is a dialogue between the beneficiary and his or her doctor or hospital, facilitated by an impartial third person (the mediator). It is an opportunity for the beneficiary and his or her doctor or hospital to tell their story, respond to each other, and resolve the concerns about the way the beneficiary was treated. Not all complaints are appropriate for mediation. A QIO physician reviewer determines if the case is suitable to be resolved by both parties. ADR - Alternative Dispute Resolution - A method of resolving a Medicare beneficiary concern. SDFMC nurse representative has direct telephone contact with the beneficiary to identify areas in which the beneficiary believes the provider could improve (usually issues related to communication, comfort, etc.). The SDFMC nurse representative shares these concerns with a representative from the provider via telephone conversation. The provider addresses each concern and sends a letter of agreement to improvement to SDFMC. SDFMC sends a letter to the beneficiary describing the changes the provider has made related to the concerns identified. Mediation Process Mediation is a form of conflict resolution that brings two parties together in a process conducted by an impartial third party (the mediator). Mediation is a process that often results in increased satisfaction to the participants. It is not a binding arbitration. Participation is voluntary. By its very nature, mediation is a process in which the parties willingly decide to participate. One or more of the parties may need to be persuaded, but it is the eventual consent of the parties that gives the mediator the authority to work with them; there is no other basis for that authority. Qualification Guidelines QIOs have two methods for resolving clinical quality of care beneficiary complaints. The first is through the process of Medical Record Review and the second is through Mediation. While mediation conceivably can be used to resolve any type of healthcare issue, mediation in the Medicare setting will initially deal with perceptions of clinical quality of care issues and communication. If the beneficiary or their representative declines the offer of mediation, the case will revert to the traditional medical record review process. Both methods of resolving beneficiary complaints will be offered free of charge. Examples of Suitable Cases for Mediation The beneficiary says they were given the wrong medicine, and the medical record shows the medicine was correct, but the instructions given were not clear or completely understood; The beneficiary's representative states his or her parent was discharged before he or she was able to walk. The medical record shows that the patient could walk with assistance, physical therapy in the home was ordered, but the family did not understand what arrangements had to be made to start the care at home; The beneficiary states that the care received from an orthopedist for neck pain did not help her. The medical record shows that the physician discussed a variety of available options for care. However, the beneficiary did not make a choice and did not return for a follow-up visit. Additional information on the medical review process, beneficiary complaints, mediation and other beneficiary protection activities performed by South Dakota Foundation for Medical Care can be found at our medical review page. Another docuent, Just Ask, has questions and answers regarding the quality of your health care. Click here for a Text Only Version of the site © 2008 South Dakota Foundation for Medical Care, All Rights Reserved