New Information on Quality of Care Complaints

I recently had a Medicare beneficiary tell me a story of how his foot got so bad off he could hardly move around his house. He went to an orthopedic surgeon, had an expensive MRI, and the surgeon and several doctors immediately urged that he quickly be operated as his condition was rapidly worsening and no other cure would work. He decided to wait, and within 10 days, he was perfectly fine. He was quite angry that not only was he completely misdiagnosed, but that the tests Medicare paid for were very expensive, and he got the idea that the surgeon had an ownership interest in the testing equipment and the surgery center they wanted him to use. He asked if there was somewhere he could lodge a complaint about all this.

While this topic is covered beginning on page 214 of Managing Your Medicare, some additional discussion is appropriate. The Centers of Medicare & Medicaid Services has contracted with a Quality Improvement Organization (QIO) in each state and territory to do a variety of tasks, one of them being to look into complaints about the quality of care given by physicians and practitioners to Medicare beneficiaries.

The Quality Improvement Organization in my state – the Georgia Medical Care Foundation – helpfully offers these as some of the specific types of issues which any Medicare beneficiaries may complain about:

Medication errors. Examples: Being given the wrong medication, or being given medication at the wrong time, or being given an overdose or underdose, or being given a medication to which you are allergic, or being given medications that interact in a negative way.

Unnecessary or inappropriate surgery. Example: Being operated on for a condition that could effectively be treated with medications or physical therapy.

Unnecessary or inappropriate treatment. Examples: Being given the wrong treatment or treatment that you did not need, or being given treatment that is not recommended for patients with your specific medical condition, or a delay in beginning your treatment.

Change in condition not treated or properly evaluated. Examples: Not receiving treatment after abnormal test results or when you developed a complication, such as an infection after surgery or a bedsore while in a skilled nursing facility.

Discharged from the hospital too soon. Example: Being sent home while still having severe pain.

Incomplete discharge instructions and/or arrangements. Examples: Being sent home without instructions for the changes that were made in your daily medications while you were in the hospital, or receiving inadequate instructions about the follow-up care you need.


And you should note that you can use this process to complain about care whether you are in Original (fee-for-service) Medicare, or in Medicare Advantage, that is, Medicare managed care. And you can use it if you received the care (or failed to receive it) in a physician or practitioner’s office, or in a variety of other healthcare settings such as hospitals (whether you were an inpatient or outpatient), ambulatory surgery centers, skilled nursing facilities, home health agencies, hospices, outpatient rehabilitation facilities, and so forth.

If you decide to file a complaint, either you or your authorized representative should call toll-free to 1-855-472-4440, or fax your written complaint to 1-855-472-4441. These connect you with the Beneficiary and Family National Intake Center. This is a brand new organization which will assist you by registering your complaint. (You should no longer call your state’s Quality Improvement Organization to do this. This new outfit is also called the Beneficiary & Family-Centered Care National Coordinating Center and the National Intake Center.)

And as indicated in the book, your complaint must be filed in writing, but even if you call, this Center will take your complaint and send it to you for your signature. Once this is received, it will proceed to formalize your complaint and send it to your state’s Quality Improvement Organization for its review. Be advised that these reviews typically take several months to complete.

But as I warned the beneficiary, he may not get much satisfaction with this process. This is because if the physician or practitioner does not consent to the release of information which the Quality Improvement Organization gathers in the course of its review, it is not allowed to disclose any specific information to you, other than it has used the information you provided to improve quality of care. My experience is that beneficiaries and their family members are bitterly disappointed by this. Somehow we are conditioned, in our adversarial society, to expect blame to be assigned and punishment to be meted out. However, the Medicare law is quite specific about this, and is designed, rightly or wrongly, to protect the review from disclosure so that the issue can be fully investigated and, if appropriate, improvement made to the care being provided.

On the other hand, if the physician or practitioner does consent to release, you will get full information on the Quality Improvement Organization’s findings regarding the issue at hand.

And you should be aware that a number of years ago a movement began to deal with the costs of medical malpractice by trying to have physicians be more open and responsive to complaints by their patients. One aspect of this is that many states have passed laws which allow physicians to apologize for errors they have made, but forbid this apology to be used against them in court. It is believed that this allows an increase in openness and dialog, which, in turn, creates a less adversarial arena in which to resolve complaints. Some recent studies have shown that this seems to be working.

Along the same vein to increase openness and dialog, the Center may, in some circumstances, ask the beneficiary to work with the Quality Improvement Organization and participate in an alternative dispute resolution process with the physician or practitioner to resolve the issue. This will be done only if both parties consent to this, and if the Quality Improvement Organization finds that there is not a serious issue with the quality of care. This process may take two forms. One is mediation, in which a physician or healthcare provider and the beneficiary have a face-to-face meeting facilitated by an impartial, trained mediator. The other is facilitated resolution, in which a "go-between" from the Quality Improvement Organization acts as the communicator between you and the physician or healthcare provider. If both parties agree, others may help in the process. Both parties have to agree that the process will be kept completely confidential. If you can’t come to an agreement or understanding, the typical case review process that Quality Improvement Organizations use will proceed.

Keywords: Quality of Care Complaints Quality Improvement Organizations QIO Beneficiary and Family National Intake Center

Originally Posted 09-10-11