Administrative Memos

200601

FROM: Theodore O. Will, Chief Executive Officer
DATE: Jan 12, 2006
SUBJECT: MEDICARE 8TH SCOPE OF WORK (SOW) ALTERNATIVE DISPUTE RESOLUTION FOR MEDICARE BENEFICIARY COMPLAINTS
IPRO CONTACTS:

Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment, extension 364; Elizabeth Hall, Director, Beneficiary Complaint Review Program, extension 364

As you may recall, during the Medicare 7th Scope of Work (SOW), IPRO was awarded a special study by the Centers for Medicare and Medicaid Services (CMS) to test an alternative dispute resolution methodology for beneficiary complaints. Based upon the positive results attained by IPRO's "Alternative Approach Improvement Methodology (AAIM)" special project that was completed in July 2005, we are pleased to again be able to offer this method as another option in the resolution of Medicare beneficiary quality of care complaints. We encourage you to consider participation in this alternative approach to complaint resolution should you be contacted by IPRO.

IPRO's initial handling of a Medicare beneficiary complaint in the AAIM process mirrors the traditional review process, i.e., the complaint is initiated via a call to IPRO's Helpline with subsequent submission of a written complaint, or as the result of written communication. However, unlike the traditional complaint review process, cases appropriate for AAIM proceed from IPRO physician review of the medical record directly to complaint resolution. As the concerns are mutually resolved by the involved parties, the end results are agreements focused on quality and/or process improvement(s).

BACKGROUND:

As the Quality Improvement Organization (QIO) for New York State, IPRO conducts review of all written beneficiary complaints about the quality of services that may be paid for under Title XVIII of the Social Security Act. This complaint process, which IPRO has conducted since program inception in 1987, provides Medicare beneficiaries and their families a forum to have quality of care concerns independently assessed and addressed across the continuum of care.

Within the last few years, CMS has implemented many positive changes to the Medicare beneficiary complaint process. QIOs, including IPRO, have implemented a case management approach for handling beneficiary complaints. In addition, when appropriate and with concurrence of all involved parties, mediation may also be offered as an alternative method to traditional case review. The latest enhancement effective August 1, 2005 (8th SOW), enables QIOs to incorporate additional alternative dispute resolution (ADR) methods such as IPRO's Alternate Approach Improvement Methodology (AAIM) into the Medicare beneficiary complaint process. These ADR options offer a significant opportunity to improve satisfaction for beneficiaries, practitioners and providers and improve the health care delivery system while still meeting statutory obligations, as referenced above.

IPRO'S ALTERNATE APPROACH IMPROVEMENT METHODOLOGY (AAIM) PROCESS:

IPRO will utilize the decision protocols outlined in the table below, to determine whether a complaint case is more appropriately resolved through traditional medical record review, mediation or if "AAIM" may be offered. The decision protocols are based upon the results of IPRO first or second level physician review of the medical record(s) pertinent to the case, as well as concurrence of IPRO's Medical Director.

Table. IPRO Complaint Resolution Decision Protocols


IPRO Physician Review Determines	Mediation	AAIM	Traditional Case Review
No quality of care concerns associated with case - no opportunities for improvement	Yes	Yes	Fallback
No quality of care concerns associated with case - care could have been better	No	Yes	Fallback
Confirmed quality of care concerns are associated with case	No	No	Yes

AAIM is a facilitated resolution process that relies on IPRO to serve as the intermediary between the complainant and the practitioner/provider. Direct confrontation is avoided through an iterative process of discussions, led by the IPRO Facilitator. When a case is deemed appropriate for AAIM, IPRO contacts the complainant to solicit their interest in participation. Subject to their agreement, we then contact the physician/provider to obtain their consent to participate. IPRO then works with all involved parties, telephonically, to help them reach a satisfactory complaint resolution.

In addition to the above, the following program elements are applicable:

Voluntary consent to participate must be obtained from all involved parties.
The case may revert to traditional medical review at any time by participant request or if the complaint cannot be resolved by the AAIM approach.
Provider/practitioner agreements regarding follow-up steps to be taken are expected to be formulated and reported to IPRO. Suggestions for quality/process improvements that would help to prevent a similar complaint in the future, will also be solicited.
All participants will be requested to complete a satisfaction survey.

SUMMARY:

IPRO's initial handling of a Medicare beneficiary complaint in the AAIM program mirrors the traditional review process, i.e., the complaint is initiated via IPRO's Helpline with subsequent submission of a written complaint, or as the result of written communication. However, unlike the traditional complaint review process, AAIM focuses on the use of the complaint as an opportunity for quality and/or process improvement; concerns are mutually resolved by the participants and the end result is an agreement focused on process improvement(s).

Should you have any questions in regard to the Alternate Approach Improvement Methodology (AAIM), please feel free to contact Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment or Elizabeth Hall, Director, Beneficiary Complaint Review Program at (516) 326-7767, extension 364.