Alternative Dispute Resolution (ADR) in the Medicare Beneficiary Complaint Response Program

Background
For several decades, Medicare beneficiaries have contacted Quality Improvement Organizations (QIOs), such as NMMRA, federally funded government contractors located in each state, when dissatisfied with the quality of health care provided by their practitioner or health care provider. Traditionally, these complaints were handled through the medical record review process. Through the Centers for Medicare & Medicaid Services, NMMRA now offers alternative dispute resolution methods to help resolve beneficiary complaints. These options include mediation, facilitated resolution and external resolution. A brief description of each method is below.

Mediation
In September 2003, NMMRA, sponsored by the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services, offered mediation as an optional method to resolve quality of care complaints that Medicare patients or their representatives file involving a practitioner or heatlh care provider. Mediation is a consensual and collaborative process in which the parties have agreed to mediate in good faith and to authorize a third party, the professional mediator, to facilitate their efforts to reach a resolution. In contrast to arbitration, the parties themselves decide on the outcome and create a mutually agreed upon resolution.

The mediation process is strictly confidential, no records are kept and anything stated in the mediation session cannot be used in any legal proceedings. If the parties reach an agreement, it will be shared with the QIO to follow up and help insure the terms of the agreement are implemented.

Facilitated Resolution
In a facilitated resolution, the QIO designates a facilitator, an intermediary who will speak to each party, in separate, independent telephone discussions. The facilitator conveys information from the beneficiary to the provider describing the identified concerns and what the beneficiary says could have happened to prevent the complaint.

External Resolution
External resolution or self resolution occurs when, in the course of pursuing one or both of the ADR options, a provider initiates a contact to the beneficiary or the beneficiary contacts the provider to discuss what might be done to resolve the complaint. External resolution addresses the issues outside of QIO involvement and it may or may not be within an organization's established complaint or patient review process.

Mediation, facilitated resolution and external resolution are voluntary and either party can withdraw at any time. The beneficiary always has the option to return to the traditional medical record review process if he/she does not believe a sense of resolution was obtained after one or more methods or ADR are attempted.

If you have questions about ADR in the Medicare Beneficiary Complaint Response Program, please contact NMMRA's helpline at 1-800-663-6351.

To request additional information about ADR, please click here. You may also access beneficiary information as well as provider information by clicking on the appropriate link.