Administrative Memos

200312

FROM: Theodore O. Will, Chief Executive Officer
DATE: Oct 23, 2003
SUBJECT: Notice of Final Disposition - Medicare Beneficiary Complaints
IPRO CONTACTS:

Andrea Goldstein, Vice President, Medicare/Federal Healthcare Assessment, extension 364

The purpose of this memorandum is to make you aware of a federally mandated change to the Medicare Beneficiary Complaint review process. Effective immediately, all Quality Improvement Organizations (QIOs) must inform complainants (i.e., beneficiaries or their designated representatives) of the final disposition of a beneficiary complaint.

Background

In 2001, Public Citizen, Inc. sued the Department of Health and Human Services (HHS) and the Centers for Medicare/Medicaid Services (CMS) contending that applicable QIO Manual instructions violated the statutory requirement that QIOs inform complainants of the final disposition of a complaint. The District Court agreed, holding that the provisions in the QIO Manual prohibiting disclosure of the results of a beneficiary complaint were contrary to law. CMS appealed that decision. On June 20, 2003, the United States Court of Appeals for the District of Columbia reached its decision in Public Citizen v. U.S. Department of Health and Human Services and Centers for Medicare and Medicaid Services and affirmed the lower court decision. Language has been developed by CMS for QIOs to utilize for the purpose of meeting the requirements of the court order. Effective immediately, all IPRO notices of final disposition on a new beneficiary complaint or one currently pending (cases in process on or after June 20, 2003) must contain a statement that the care in question "did or did not meet applicable professionally recognized standards of health care".

IPRO Review Process

As the QIO for New York, IPRO reviews all written quality of care complaints received from Medicare beneficiaries or their designated representative. All beneficiary complaint cases are subject to the traditional QIO case review process. This includes initial review of the case by a peer reviewer. Should quality of care concern(s) be identified, the involved parties are afforded an opportunity to respond/discuss the case. A second level peer review is then conducted and a final determination is made. Should quality of care concerns be upheld, the involved parties are afforded an opportunity to submit additional information and request re-review by a peer who has not previously reviewed the case.

In the situation where a case has undergone this complete review process and the quality concern is upheld, the IPRO reviewers and Medical Director will now also make a determination as to whether the care met or did not meet applicable professionally recognized standards of health care. This determination will be guided by the following:

Nationally recognized guidelines/policies developed by the relevant medical society (relevant guidelines to be referenced); OR
Standard textbooks in the related field(s) of medicine (text used to be referenced).

As in the past, when there is practitioner consent to disclose, information will be provided to the beneficiary/representative by IPRO in the same manner as under the current CMS policy. It should also be noted that provider-specific information continues to be considered non-confidential and is disclosable as long as it does not explicitly or implicitly identify a practitioner, QIO reviewer or patient who has not consented to disclosure.

If you have any questions in regard to this memorandum, please feel free to contact Andrea Goldstein, Vice President Medicare/Federal Healthcare Assessment, extension 364.