A. Beneficiary Complaints

Under Medicare law, Quality Improvement Organizations (QIOs) review complaints about the quality of care that Medicare patients receive. The complaints come from Medicare patients and/or their representatives. In reviewing a complaint, the QIO looks at the services a patient received and decides whether those services met standards of health care that are commonly accepted by physicians and others in the medical community.

Quality of care complaints may involve more than one concern, due to the following: (1) more than one quality of care concern in a single setting; (2) the same quality of care complaint for a single patient episode of illness involving multiple settings and/or providers; (3) or more than one quality of care concern involving more than one setting and/or provider. For example, a Medicare beneficiary complaint related to a hospital stay might include several different quality of care concerns or a beneficiary who was hospitalized and then moved into a skilled nursing facility or other outpatient hospital setting might have the same quality of care concern occur in each type of setting. Consequently, for a specific Setting or Provider type, the number of quality of care concerns confirmed by the QIO may exceed the number of beneficiary cases reviewed.

Beneficiary Complaint Cases: Number and Review Results

*Total Cases Abandoned or Withdrawn by Beneficiary or Representative or No Medical Record Received: May represent a variation in level of effort from those cases Abandoned or Withdrawn or for which no medical record is received early in the process to those Abandoned or Withdrawn or for which no medical record is received later after more resources are expended

Complaint Cases by Setting or Provider.

Complaint Cases by Type of Problem

The numbers below represent only complaints by beneficiaries or their representatives. They do not include any other QIO reviews of medical services.

The numbers below represent only complaints by beneficiaries or their representatives. They do not include any other QIO reviews of medical services.

B. Beneficiary Notice Reviews

Under Medicare law, QIOs review the need for inpatient hospital care. They help determine whether a patient received care in the proper place or "care setting." This review may take place at two different times, either during or after a hospitalization. In the first instance, patients or their representatives ask the QIO to review a "Hospital Initiated Notice of Non-Coverage," or HINN, in which the hospital informs a patient that either an admission or a continued stay in a hospital is not needed. In such cases, the QIO conducts an "immediate review," whereby the QIO reviews the case (within 2 working days following the beneficiary’s request for a pre-admission or admission HINN and within 30 days for review after discharge or when the beneficiary was not admitted to the hospital) and issues either a denial notice or a notice explaining that the care would be, or is, covered. In other cases where a hospital issues a HINN, but the patient does not immediately ask for a review, the QIO automatically reviews the case after the fact in what is called "retrospective review." In all reviews, the QIO staff looks carefully at the patient’s medical record to decide if an admission or continued stay is/was needed.

9SOW-PR-3A-11-185. This material was prepared by QIPRO, the Medicare Quality Improvement Organization for Puerto Rico, under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The content of this material does not necessary reflect CMS policy.