Beneficiary Appeals and Complaints

MPRO reviews quality of care provided to Medicare beneficiaries. In addition, in its role as a Quality Improvement Organization, QIO, MPRO reviews beneficiary appeals of certain provider notices, and implements quality improvement activities as a result of care review activities. Individual patient complaints and provider medical reviews are important starting points for analysis of quality improvement needs among providers. MPRO works to link care review activities to improvements in the quality of care, specifically by developing quality improvement activities focused on system-wide changes.

Under Medicare Review, specific reviews include:

• Medicare Important Message
• Medicare Advantage: Fast Track Appeals
• Benefits Improvement and Protection Act (BIPA)
• Higher Weight DRG (HWDRG)

MPRO will no longer conduct Hospital Payment Monitoring activities since this is not a federally funded initiative beginning on August 1, 2008. Resources to assist you may be found at www.HPMPresources.org, or by contacting your fiscal intermediary.

Overview

MPRO is charged with carefully reviewing Medicare Beneficiary complaints to determine whether a clinical quality of care problem exists. The review determines professionally recognized standards of care were met. Although possible, a beneficiary complaint is rarely a utilization or DRG issue. Complaint reviews encompass all Medicare provider settings. Beneficiary complaints can be from the beneficiary or their representative, but must be submitted in writing.

If the physician reviewer determines a potential quality of care concern exists, MPRO sends a letter to the attending physician or provider to allow opportunity for discussion. Physicians and providers must submit their response in writing, but the physician or provider may contact one of MPRO’s physician reviewers to discuss the case in addition to the writter response.

Upon review of the beneficiaries medical record, if the physician reviewer determines there is no evidence of a clinical quality of care concern, Alternative Dispute Resolution (ADR) may be considered an option for resolving the complaint regardless ADS is voluntary, collaborative and, although applicable to a broad range of complaints, it is particularly suited to handling communication and personal interaction issues. For approved cases, physician reviewers should note whether the case would be appropriate for mediation. If the physician reviewer does not make a note on the PRAF, the case manager may contact the physician reviewer to discuss the option for potential mediation.