Center for Medicare Advocacy Conference
Develops Medicare Beneficiary Complaint Process


The Center for Medicare Advocacy, Inc., (the Center), convened a working conference in January 2007 that designed a model for resolving Medicare beneficiaries’ complaints about quality of care. Sponsored by the Commonwealth Fund, with assistance from AARP, the conference provided a forum for key stakeholders to discuss concerns and develop a blueprint for change.


Medicare beneficiaries and their advocates are concerned that this current process for resolving beneficiary complaints about quality of care has not been effective in providing fair and timely resolution of complaints. Concerns about the process include an inadequate resolution of beneficiary complaints about poor quality, a lack of information about proper care protocols, and the failure to provide expedited review of denials of care.


Conference Overview


The Center’s conference was triggered in part by the national Institute of Medicine’s (IoM) comprehensive study in 2006 of Medicare’s current beneficiary quality of care complaint process.  The IoM and others had on many occasions called for a beneficiary-focused complaint review process. The current process, operated under a contract with Quality Improvement Organizations (QIOs) has been found to be primarily provider-focused, assisting providers in quality improvement activities, rather than beneficiary-focused.  The IoM, as a result of its cumulative findings, recommended removing the function of performing quality of care investigations from the QIOs and allowing other entities to perform this work while QIOs continue to focus more specifically on assisting health care providers in quality improvement.


Prior to the conference, the Center commissioned three background papers to provide a framework for discussing these topics and others related to quality review.  Forty-two experts in fields ranging from direct patient care to Congressional staff reviewed these pieces and participated in the day-long conference to produce a model complaint process.


The Model Complaint Process


An overview of the quality complaint model designed by the conference and a short description of its elements are provided below:


1.      Filing Complaints


·         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.


·         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.


·         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.


2.      Goals of the Complaint Process


·         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.


·         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.


3.      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.


·         The Patient Advocate Link (PAL)


Conferees developed the notion of a PA to help beneficiaries access and work through the complaint process.  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.


·         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.


4.      Qualifications of a Quality Review Entity


·         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.


·         Referral


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


·         Centralized Database


The complaint information should be entered in a centralized database.


5.      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.


·         Providers

·         State Survey Agencies

·         State Medical Boards

·         QIO Retention of Current Role

·         Other Potential Entities

·         A Hybrid Approach


6.      Data Should be Gathered and Used for Quality Improvement


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


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


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


·        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.


Next Steps


The Center for Medicare Advocacy will continue to advance the work of the Quality Review Conference in a variety of ways.  These will include the following:


  1. Work with CMS staff to (a) expand its approach to the beneficiary quality of care complaint process to include exploratory models using medical boards and state licensing agencies, at least on a demonstration project basis, to test efficacy and efficiency; and (b) to embrace a set of initiatives to provide more Medicare beneficiary education about the current Medicare beneficiary quality of care complaint process.


  1. Work with the American Health Quality Association, the organization that represents all of the QIOs, pending any movement of the complaint process, to improve their education and outreach efforts toward beneficiaries.


  1. Seek funding for a Public Policy legislative “roundtable” targeting Congressional staff to alert members and staff to the issues raised at the conference, highlighting the beneficiary complaint model separate from the functions of the QIO as a viable legislative goal.


Further Information


Materials from the conference, including the background papers and the narrative of the conference proceedings are posted on the Center’s website at


Correspondence, questions, or comments regarding this conference should be sent to:

© Center for Medicare Advocacy, Inc.