Mediation available to resolve Medicare beneficiary complaints

OAK BROOK, Ill.—Under Medicare’s Quality Improvement Organization program, Medicare beneficiaries will be able resolve quality of care complaints against health care providers or physicians through an optional mediation program beginning this fall.

The new program, sponsored by Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, will bring together a provider or physician and a patient or his/her representative for a face-to-face meeting facilitated by an impartial mediator. This mediation is an alternative to the traditional medical record review process.

“Mediation allows a physician or health care provider to engage in a discussion with a patient who has filed a quality of care complaint against him/her,” said Sandy Hall, spokeswoman for the Illinois Foundation for Quality Health Care, Illinois’ Medicare quality improvement organization. “It allows both parties a chance to tell their side of the story and resolve their disputes in a neutral and confidential environment.”

“Mediation will not be available if a serious quality of care concern appears to be involved,” said Hall. “However, with up to 80 percent of quality of care complaint cases driven by lack of communication or parties’ concerns about their interaction with physicians or providers, mediation can help resolve complaints faster, resulting in higher satisfaction rates for providers, physicians and patients alike. More importantly, it can help prevent the case from getting into the highly adversarial process of litigation.

Currently, each beneficiary complaint goes through a medical record review process that can last anywhere from 85 to 165 days, depending on whether a quality of care concern is found. To file a complaint or seek mediation, call 1-800-647-8089.

After a complaint is received, the QIO determines its suitability for mediation. If the case is found to be suited for mediation, the review case manager will contact the beneficiary and physician or provider to offer this new option. Both parties have to agree to participate in order to proceed. A mediation session would be conducted face-to-face, or occasionally by phone if the two parties involved are unable to meet at the same time and place because of distance or disability. A typical mediation session takes between two and four hours.

“Mediation is not the time-consuming process some people think it is,” adds Hall. “Actual mediation may only take a few hours, and when an agreement is reached, the patients dissatisfaction is relieved and the physician or provider is saved from more time consuming processes, such as the traditional medical record review process, licensing investigation or litigation.”

Key features of mediation process

• The process is facilitated by a professional, impartial mediator.

• Participation in mediation, at no cost to either party, is voluntary.

• The session is strictly confidential. No records are kept of the proceedings. By law, nothing that is said can be used against anyone in court or for other purposes.

• Each party is given a chance to tell his/her story and to respond to statements being made.

• Either party can withdraw from the process at anytime.

During a mediation session, the mediator helps the parties come to an agreement, and to interpret what is being said and what is happening in the exchanges between both parties.

A successful mediation usually results in an agreement being signed by both parties.

The national mediation program, which began in the fall of 2003, has been preceded by a successful six-state pilot project that was conducted in 1998-1999. Evaluation of the pilot suggested that most beneficiaries and providers who had participated in mediation were satisfied with both the process and the outcome.

The Illinois Foundation for Quality Health Care is a non-profit agency contracted with CMS to improve the quality of care provided to Illinois’ Medicare population. IFQHC provides education programs to doctors, hospitals, nursing homes and home health care agencies and conducts outreach programs for beneficiaries.

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