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.

Downloads
There are no Downloads
Related Links Inside CMS
There are no Related Links Inside CMS
Related Links Outside CMS
MedQIC AHQA

Page Last Modified: 12/14/2005 12:00:00 AM
Help with File Formats and Plug-Ins