Background Information

Medicare and the Quality Improvement Organization

The Centers for Medicare & Medicaid Services (CMS) funds and regulates Medicare, the country's largest health insurance program. Medicare is a health insurance program for people 65 years of age and older, some disabled people under 65 years of age, and people with End Stage Renal Disease (permanent kidney failure treated with dialysis or a kidney transplant). Most people are eligible at the age of 65 for Medicare medical benefits.

In 1982, Congress established Utilization and Quality Control Peer Review Organizations ("PROs", now known as Quality Improvement Organizations, or "QIOs"). The QIOs in each state perform two broad functions: (a) promote quality health care services for Medicare beneficiaries and (b) determine whether services rendered are medically necessary, appropriate, and meet professionally recognized standards of care.

QIOs work with a range of different individuals and organizations. Some of the key players are beneficiaries (Medicare health insured members), physicians, and healthcare facilities such as: acute care, home health care, and skilled nursing facilities.

Beneficiary Complaint Response Program

Each QIO is involved in many different programs involving quality improvement. Beneficiaries, who have a concern or are not satisfied with the care they receive, can file a written complaint with the QIO.

If a beneficiary decides to make a formal complaint, the QIO assists them in putting their complaint in writing. Some of the typical types of complaints that beneficiaries file with a QIO may be for issues such as:

Received the wrong medication
Underwent inappropriate surgery
Received erroneous dose of medication
Received an error in treatment
Received inadequate care or treatment by any healthcare professional
Discharged beneficiary too soon
Change in the condition was not treated
Received inadequate discharge instructions

Once the QIO receives a complaint in writing, the quality of care review begins. This is a free service for Medicare beneficiaries.

Medical record review (MRR) is the traditional peer review process for handling beneficiary complaints. The MRR, in its conventional form, focuses exclusively on the medical records related to the complaint. The purpose is to determine whether usual guidelines or expected practice have or have not been adhered to in the particular complaint being addressed.

Some of the major complaints that beneficiaries have had about the MRR process include:

Beneficiaries feeling like they aren't heard, no interaction or dialogue
There is no documentation in the medical record of their concern
The beneficiary will only receive results of complaints about physicians or practitioner if the physician gives consent. Otherwise a more generic letter explaining the review process, in general, is sent to the beneficiary.

Due to a high level of dissatisfaction among beneficiaries with the traditional medical record review, the mediation option is being implemented as a new alternative to this process. Mediation is a consensual and collaborative process in which the parties have agreed to mediate in good faith and to authorize a third party, the mediator, to facilitate their efforts to reach a resolution of their conflict. In contrast to arbitration, the parties themselves decide the outcome and create a mutually agreed upon resolution to resolve the conflict. The primary focus of the mediation is on the relationship between the parties and the development of each person's insights into self as well as into the other person's perceptions.

Mediation addresses those criticisms that beneficiaries often express about MRR, the lack of "voice" in the process, the lack of information during the process and, the exclusive focus on medical records. Mediation gives the beneficiary the opportunity to be heard. The apparent emotional issues of beneficiaries can also be resolved, anger can be defused through personal interaction and the process can lead to a sense of closure about a disturbing event. Mediation is usually concluded faster than the MRR process, is always confidential as is MRR, and helps develop positive relationships for the future.

While mediation conceivably can be used to resolve any type of healthcare issue, it will initially deal with perceptions of quality of care issues and communication.