A working conference convened by the Center for Medicare Advocacy, Inc., supported by the Commonwealth Fund, a New York City-based private foundation, and AARP

January 19, 2007

Conference participants agreed to a consensus model Medicare beneficiary complaint review system. The elements of that model as well as a short description of those elements are provided below. More details about how these elements were agreed to are available in the Narrative of the Conference Proceedings.

I.              Filing Complaints

A.     Definition of “Complaint” Should be Construed Broadly

Participants agreed that the definition of “complaint” should be construed broadly. An ideal system would be able to accept and document the broad array of potential complaints. It would also be flexible enough to allow for an appropriate method of resolving the complaint, based on its severity and other factors.

B.     Anyone Can File a Complaint

Participants agreed that anyone should be able to file a complaint. There was consensus that an ideal system would receive and follow through on complaints from beneficiaries, family members, advocates, health care workers, and anyone else with important information. The system would need the means to protect the anonymity of staff and comply with HIPAA.

C.     Neither Language nor Technology Should Discourage Complaints

The ability to file a complaint should not be constrained by language, literacy, or technological barriers. The complaint process should utilize materials that are age-appropriate and should recognize that primarily Internet-based systems are not effective with the current Medicare beneficiary population.

II.           Goals of the Complaint Process

A.     The Primary Goal is Addressing Beneficiary Concerns

Participants agreed that the primary goal of the complaint process system should be to address and resolve beneficiary concerns.

B.     A Secondary Goal is Identifying Provider Opportunities for Quality Improvement

In addition to focusing on the beneficiary, it was agreed that the complaint system is an overarching part of a system’s quality control key to the proper function of any system that delivers a service. Participants agreed that a well-publicized complaint
system that keeps detailed records can identify problems with specific providers and identify areas where a specific provider or all providers can improve their quality.

III.         There Should be a Single Point-of-Entry for Beneficiaries

There should be a single point-of-entry for beneficiaries and anyone else who wishes to file a complaint—one number to call regardless of where they live.

A.     The PAL

The PAL would be an outlet for the beneficiary for purposes of advice about options or assistance in making preliminary inquiries about quality of care concerns and to facilitate provider feedback.

B.     Regulatory Capacity of a “PAL” Single Point-of-Entry Entity

The PAL would not investigate and would not make decisions of right and wrong but would make referrals, listen to the beneficiary, and keep the beneficiary informed of the progress of the complaint.

IV.        Qualifications of a Quality Review Entity

A.     Intake and Review

The first person to answer the phone has to be one of the most capable staff members—efficient, respectful, culturally competent, and patient.

B.     Referral

The referral of the case has to be to the appropriate person or entity for investigation and/or resolution.

C.     Centralized Database

The complaint information should be entered in a centralized database.

V.           Possible Referral and Resolution Entities

            Participants discussed, but did not reach a consensus on, which entity or entities should be responsible for investigating and reviewing complaints.

A.     Providers

B.     State Survey Agencies

C.     State Medical Boards

D.     QIO Retention of Current Role

E.      Other Potential Entities

F.      A Hybrid Approach

VI.        Data Should be Gathered and Used for Quality Improvement

Data that are gathered by the complaint system should be used for quality improvement purposes.

VII.      The Complaint System Should be Evaluated on a Regular Basis

A.     The complaint system itself should be regularly evaluated. Participants agreed that the system should examine its own interagency communication mechanisms.

B.     The system needs meaningful feedback to be able to know how satisfactorily it resolves problems both from a beneficiary perspective and that of state and federal regulators