Responding to Beneficiary Complaints

Under our Quality Improvement Organization (QIO) contract with Medicare, Qualis Health is charged with responding to Idaho and Washington Medicare beneficiaries' complaints regarding the quality or necessity of their care.

If the case appears to be a good candidate for mediation or facilitated resolution, we may refer both the patient and the provider to these services instead of, or in addition to, the medical record review. Participation in these services is voluntary.

Federal laws control the way we investigate and respond to beneficiary complaints. Our findings are not allowable in court, and do not directly affect coverage, payment, or billing.

Our Medical Record Review Process
When we receive a written complaint from a Medicare beneficiary, we will contact his or her provider to get a copy of the medical record, then assign an independent physician to review it.

Our physician reviewer will evaluate the medical record and try to determine whether the care put the patient's health at risk.

• If the reviewer determines that the care met professionally recognized standards, the medical record review will be closed. In some cases, mediation or facilitated resolution may be suggested.
• If the reviewer identifies a potential concern regarding the quality or necessity of the care, the provider will be contacted and given an opportunity to send clarifying information.

After examining the additional information, our physician reviewer may close the medical record review, refer the case to an alternative process, or confirm that there is a valid concern regarding the quality or necessity of care provided.

If requested by the beneficiary's provider, the case may be re-reviewed by a second independent physician.

Our decision is based on the medical record. We do not perform other kinds of investigation, such as interviews or site visits.

Follow-Up Activities
If we determine that the care put the patient's health at risk, we will work closely with the provider to prevent this problem from happening again.

In some cases, there may be an opportunity to make broader process changes that improve the quality of care for patients throughout the system. These more in-depth projects include working with the provider to:

• Perform a root cause analysis
• Develop and implement a systemwide improvement plan
• Monitor results over a 12-month period

At the conclusion of the systemwide improvement project, we will document the progress made and the strategies used to successfully implement changes. The final report is provided to CMS.

Protected Information
The results of our review are added to a governmental tracking database.

Within federal guidelines, the Medicare beneficiary's practitioner will be able to choose how much detail about our decision is shared with the beneficiary. Facility information that does not explicitly or implicitly identify an individual is not confidential and may be released to the beneficiary.

Our findings are not allowable in court.