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Filing a Complaint Related to Your Healthcare

If your concern is

  1. related to the quality or necessity of care provided (see sidebar for an explanation of "quality or necessity of care"), and
  2. that care is covered by Medicare, and
  3. the care was provided in Idaho or Washington (if the care was provided in any other state, please call 1-800-MEDICARE)

then you may start the complaint process. Please submit the form describing concerns about your own care or complete the form packet if you are submitting a complaint on behalf of a Medicare beneficiary.

After we have received the completed complaint form, you will be assigned a case manager who will keep you updated throughout the entire process. However, please note that federal laws control the way we investigate and respond to your complaint. The law limits the amount of information we are allowed to share with you. Our findings are not allowable in court, and do not directly affect coverage, payment, or billing.

Our complaint-resolution services

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:

 

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.

What's meant by "quality or necessity of care?"

Medicare's medical review process focuses on concerns related to the "quality or necessity of medical care."

Examples include preventable situations in which the care caused you harm, or put you in a situation where you could have been harmed, such as:

  • You received a medication or treatment that you did not need
  • You were not properly evaluated for a problem, and because of this you did not receive the treatment you needed or the treatment was delayed
  • You were discharged from the hospital too soon, or with incomplete discharge instructions
  • You experienced serious complications as a result of care, the lack of care, or because the care was provided in an inappropriate setting (for instance, in a nursing home instead of a hospital)

Medicare's complaint-resolution process does not investigate issues related to unprofessional or impolite behavior, housekeeping, or the temperature of your room or food. For help with these concerns, please review our list of suggested resources.

Need help deciding?

If you would like help deciding whether our complaint-resolution services are appropriate for your case, please call 1-800-MEDICARE (1-800-633-4227, or TTY/TTD 1-877-486-2048 for the hearing and speech impaired). If your care was provided in Idaho or Washington, you will be connected with our helpline.