Beneficiary Complaints and Potential Quality of Care Concerns

NMMRA is the state organization designated by Medicare to conduct quality of care reviews upon request. Such requests can be made if a Medicare beneficiary or his/her representative has a concern about the quality of health care provided or the appropriateness of the medical treatment received for a specific health condition.

Quality of care reviews do not involve billing concerns, administrative problems, denial of services, or any other non-medical complaint that cannot be found in the medical records. Even if a concern does not meet the criteria for a quality of care review, we are able to refer it to the appropriate organization.

A beneficiary or his/her representative can either call the NMMRA Helpline at 1-800-663-6351 or write NMMRA to request a quality of care review. NMMRA collects the beneficiary information, requests the medical records from the facility in which the patient received care, and examines the records.

The review process can take up to 165 days because every effort is made for all parties to discuss the care that was given.

The skills of a physician peer reviewer, an independent physician with training and specialization appropriate to the case being examined, are used to make the most fair decision possible on whether the care provided to the beneficiary met recognized standards of care.

Beneficiary Complaint Review

CMS requires that NMMRA review all written complaints received from Medicare beneficiaries or their designated representatives alleging that the quality of services covered by Medicare does not meet professional recognized standards.

Scope of Review

NMMRA reviews all complaints that fall within its review jurisdiction and where the medical record is available, regardless of when the services were furnished. NMMRA reviews complaints involving FFS and services provided or arranged by a Medicare Advantage organization for which Medicare payment may otherwise be made with specific conditions are met.

Type of Services

The services that NMMRA reviews must be covered by Medicare regardless of whether they were covered for this particular beneficiary or whether Medicare payment was made. For example, NMMRA reviews the Medicare covered services provided in a Medicare certified skilled nursing facility (SNF) or SNF distinct part of a hospital, even if the beneficiary's SNF days may have been exhausted at the time.

Source of Services

The services must have been furnished by a provider or practitioner that, at the time services were furnished, was participating in the Medicare program. Sources of services include:

• Ambulatory surgical centers (ASCs);
• Comprehensive outpatient rehabilitation facilities (CORFs);
• Emergency rooms (ERs);
• Home health agencies (HHAs);
• Hospices;
• Hospital outpatients areas (HOPAs);
• Inpatient hospitals/units;
• Outpatient physical therapy and speech/language pathology services;
• Critical Access Hospitals (CAHs);
• Skilled nursing facilities (SNFs);
• SNF swing beds within inpatient hospitals/CAHs;
• Specialty hospitals (e.g., psychiatric and rehabilitation);
• Physicians' offices; and
• Community mental health facilities (CMHFs).

Regulations authorize NMMRA to access and review medical records pertinent to health care services furnished to Medicare beneficiaries and held by any institution or practitioner in the QIO area. NMMRA reviews complaints involving end stage renal disease (ESRD) services that relate to general services and patient services, SNF, HHA, ER, ASC, or HOPA services. NMMRA will refer complaints relating to ESRD dialysis facility services or conditions to the appropriate ESRD network organization.

Complaints That Do Not Meet Statutory Requirements

Regulations require NMMRA to conduct an appropriate review of all written complaints about the quality of services covered by Medicare, if the complaint is filed by an individual entitled to Medicare benefits for such services or by a person acting on the individual's behalf.

Complaints That Do Not Involve Quality Issues

When a complaint involves a FFS utilization issues rather than a quality issues, NMMRA conducts a utilization review (i.e., for medical necessity/appropriateness of setting). As with quality complaints, FFS utilization complaints must be submitted in writing by the beneficiary or representative. When a complaint involves both quality and FFS utilization issues, NMMRA processes each issue separately. NMMRA prepares an acknowledgment, requests and receives medical records, conducts utilization reviews, completes the PRAF when the case is referred for physician review, and denies payment or sends initial denial notices, when appropriate. NMMRA also may conduct a reconsideration review, when requested.

Beneficiary Complaint Review Process

The following actions will occur as part of the beneficiary review process:

• Complaints are received by a Review Case Manager (RCM) via phone or mail, who explains to complainant review procedure and his/or her responsibilities
• Consent packet sent to complainant, including:
  • Acknowledgment letter with summary of concerns
  • Request for additional information
  • Consent to refer your concerns
  • Consent to disclose your identity
  • Designation of representative
• Upon receipt of complainant consent, medical records are requested of the physician or provider
• Independent physician peer reviewers (PPR) provide concurrent or retrospective review
• Notice of PPR determination is made to physician and/or provider
• Physician/provider is given option for re-review
• Notice of disclosure is afforded, allowing the:
  • Provider/involved practitioner to comment on the final response to the complainant
  • Involved practitioner to consent to or prohibit the disclosure of review findings to the complainant
  • Involved practitioner/attending physician to render an opinion regarding the appropriateness of direct disclosure to the beneficiary (i.e., whether releasing review findings directly to the beneficiary would be harmful).
• Determination notices for complaints involving providers are sent to the provider and the attending Physician
• Determination notices for complaints involving practitioners are sent to the involved practitioner and the attending physician
• Complainant is notified, by mail, with the results of the review
• Complainant contacted by RCM department for follow-up satisfaction survey

For more information on medical reviews, contact Andy Romero, case review and beneficiary services manager, at (505) 314-9009.