Understanding Medicare’s Complaint Process
Medicare has contracted with Qualis Health to respond to Idaho and Washington beneficiaries’ concerns about their healthcare. When you call 1-800-MEDICARE, you will be connected with our helpline if your care was provided in either of those two states.
Our trained staff will talk with you (or your authorized representative) about your concerns. We will help you decide whether our services are appropriate for your case. Medicare's complaint-resolution process is intended only for those concerns related to the quality or necessity of care provided.
We offer the following free services to address the concerns you might have about the quality or necessity of your care. Each is described in more detail below.
- Medical record review
- Mediation
- Facilitated resolution
Reviewing Your Medical Record
An independent physician (one who does not have a relationship with your healthcare provider or the place where you received care) will review your medical record and determine whether the care you received was similar to what would have been given to you by most healthcare providers. This is called “meeting professionally recognized standards.”
Our decision will be based on the information written in your medical record. We cannot do other kinds of investigation, such as interviews or site visits. If there is not enough information documented in your medical record that relates to your concern, we will not be able to make a decision one way or the other.
If we determine that your care did not meet professionally recognized standards, Qualis Health will work with your healthcare provider to make changes and improve future care.
For more information about Medicare's medical record review process, please see:
- Our brochure, What's Next? Understanding what happens after you file a quality-of-care complaint with Medicare
- An article describing one man’s experience with Medicare’s review process.
Mediation and Facilitated Resolution
If your case appears to be a good candidate for mediation or facilitated resolution, we may refer both you and your healthcare provider to these services instead of, or in addition to, the medical record review.
Mediation and facilitated resolution provide an impartial, effective means to resolve communication problems.
- Mediation may take place over the phone or face-to-face.
- In facilitated resolution, the parties do not have any direct contact. All communication occurs by phone or mail and is channeled through the facilitator.
The goal of these methods is to resolve the issue to both parties’ satisfaction. Participation is voluntary.
