A Cautionary Tale: Know the Process for Medicare Quality of Care Complaints

The North Carolina Medical Society (NCMS) Solution Center recently received a call from a member who wanted to share an unfortunate experience with a Quality of Care complaint made through Medicare’s Quality Improvement Organization (QIO). After researching the issue, the NCMS discovered changes in the process you should be aware of so you’re not caught off guard.
In this member’s case, they were not aware of a reconsideration option now available that allows a second peer reviewer to examine all documentation associated with the complaint. Read a memo from the Centers for Medicare and Medicaid Services (CMS) that outlines these changes. Ultimately, after the reconsideration by a second peer reviewer, the final determination in this particular case was found in favor of the beneficiary.  A final determination completes the review process regardless of any pertinent follow-up information.  Now, a Senior Medical Officer from the Quality Innovation Network (QIN)-QIO will contact the physician in this case to start the Quality Improvement Project process. Learn more about what a Quality Improvement Project entails.
Here is what you need to know about Medicare Quality of Care complaints:

• The QIO program is part of the U.S. Department of Health and Human Services’ National Quality Strategy. QIO’s are made up of a group of clinicians, health care quality experts and consumers focused on improving the efficiency, effectiveness, economy and quality of care delivered to people with Medicare.
• Currently CMS relies on two types of QIOs, Beneficiary and Family Centered Care (BFCC) QIO and Quality Innovation Network (QIN) QIO. The BFCC-QIO assists Medicare beneficiaries to exercise their right to high-quality health care by managing beneficiary complaints and quality of care reviews.  The QIN-QIO is designed as a bridge between Medicare beneficiaries, providers and communities to ensure patient safety, coordinate post-hospital care transition, improve health in the communities and improve clinical quality. Alliant Quality is the vendor for the QIN-QIO; KEPRO is the vendor for the BFCC-QIO.
• For a complaint to be eligible for a Beneficiary Complaint Review ALL of the following requirements must be met.

1. Relate to the quality of care received by a beneficiary, regardless of whether the beneficiary or Medicare paid for the care, but for which payment may otherwise be made under title XVIII;
2. Be written (includes email, facsimile or hard-copy submission); and
3. Express concern about the quality of care received.

• Once a complaint is received and is determined to be eligible for a Quality of Care review, the BFCC-QIO generally takes the following steps:

1. A request for medical records is sent to the provider’s practice stating it is in response to a beneficiary complaint.
2. The QIO reviewer, who is anonymous, from the same state, and who practices in the same specialty/sub-specialty, will review the complaint, medical records and standards of care to date to make an interim initial determination.
3. The BFCC-QIO will notify the provider via phone, within 10 calendar days of the receipt of medical information, of the interim initial determination if it is found that the provider has not met the standards of care. The BFCC-QIO representative will notify the provider that he/she has seven calendar days from the date of the call to discuss the interim initial determination in writing or by phone. (The discussion period does not allow for new or additional medical information to be submitted.  That is for the reconsideration process.)
4. Once a discussion has been completed or a letter sent in lieu of a discussion from the provider, the reviewer will make the final initial determination, and send it in writing to all of the parties involved within five calendar days of the completion of review.
5. A beneficiary or provider may request a reconsideration within three calendar days of the receipt of the final initial determination notification if they are dissatisfied with the results of the final initial determination.
6. If a reconsideration is granted then a second anonymous peer reviewer will be given all of the medical information received by the QIO, the initial determination letter with right to request reconsideration, and any new evidence submitted with the reconsideration request. NOTE: The other party is not aware of the reconsideration request and approval or any new evidence, nor is the other party given an opportunity to submit additional documentation.
7. If a reconsideration is granted then a second anonymous peer reviewer will be given all of the pertinent information from the initial determination (interim and final) by the BFCC-QIO.
8. The Reconsideration Peer Reviewer has five calendar days from receipt of information to make a final determination and notify (by phone then in writing the following day) the beneficiary and provider involved. This final determination cannot be reconsidered.
9. If the provider is found outside of the established standards of care then they will be contacted by one of the Medical Directors from the QIN-QIO to discuss and implement a quality improvement plan/project.

• A quality of care complaint determination is not discoverable nor is it turned over to the relevant licensing board (with exception to extreme circumstances). However, if a provider fails to comply with any of the steps in the process they could be reported to the Centers for Medicare and Medicaid Services, which may suspend or terminate the agreement permitting the provider to care for Medicare and Medicaid beneficiaries and/or refer the matter over to the State Board of Licensing.*

*5125.2.1 – Unwillingness to Cooperate (Rev.28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) In some instances, the practitioner(s) and/or provider(s) may clearly express intent not to cooperate with the QIO for Quality Improvement Initiatives. In these situations, the Quality Innovation Network-QIO should advise the practitioner(s) and/or provider(s) that the matter may be referred to the CMS COR (or to a State survey agency through the regional office). In addition, a QIO may refer the matter to other CMS contractors (e.g., Medicare Administrative Contractors), with appropriate review authority over the practitioner’s and/or provider’s activities or to the State Board of Licensing. The practitioner and/or provider(s) may also be subject to additional reviews focusing on identified areas of concern in appropriate situations. NOTE: Failure to agree to or participate in a Quality Improvement Initiative is not justification for referral to the Office of Inspector General (OIG) for possible sanction action.
The 150-page CMS QIO Manual is the comprehensive guide to this process.