Concerns About Clinical Quality of Care

People with Medicare have the right to question the quality of care they received. Stratis Health, Minnesota’s Medicare Quality Improvement Organization (QIO), may be able to help you, through our review process.

Stratis Health has conducted medical case review for over 40 years. We determine whether services provided were reasonable and medically necessary, were provided in the most appropriate setting, met professionally recognized standards of health care, and were appropriately billed. The main goal of the QIO review process is to work with people who have Medicare (and their loved ones), and with the health care community, to continue improving health care delivery in Minnesota.

If you believe you or your family member/dependent is not receiving quality medical care:

1. Discuss your concerns with the health care facility and/or doctor providing your treatment. Most facilities have patient relations staff who can help you. They will work to understand your situation and address your concerns.
2. If Step 1 does not work, and your concern is a quality-of-care concern for services paid by Medicare, call Stratis Health’s Medicare Helpline at 1-800-444-3423.
3. Stratis Health will assist you to:
   • File a complaint
   • Understand the complaint process
   • Track the complaint until the process is complete

If you would like to consider other options to address your concern see the list of additional resources to help you determine the appropriate organization to contact for assistance.

Stratis Health's role in reviewing quality of care concerns

Stratis Health will work with you to identify the best way to address your concerns. If your concern needs a medical record review, Stratis Health will complete the review.

The purpose of the review is to help health care providers improve the care they give to all of their Medicare patients. The lessons from the case review are used to develop quality improvements focused on improving health care for all Minnesotans. This supports the Minnesota health care community’s approach to reducing medical errors.

The process:

1. A nurse from Stratis Health will talk with you to understand your concerns and will discuss how we will address your concerns. You will be updated during the review process.
2. A copy of your medical record(s) will be requested from any doctor, hospital, nursing home or other health care provider named in your complaint. Your medical record includes any lab tests, x-ray results, doctor’s orders, nurse’s notes, treatments and the medication you were given.
3. A doctor will review your case. This “physician reviewer” does not know you, the doctor involved, or the place where the care was provided. Not having those connections lets him or her give an honest, independent opinion. The physician reviewer will:
   • Review all available medical records and your original complaint
   • Evaluate details of the medical care you are questioning
   • Make a decision about the quality of services you received

Outcomes/review results

After the review is completed, we send you a letter explaining our findings. Federal law limits what we can tell you. The law also lets your doctor limit what we can share with you.

We may only be able to tell you if the care you received met professional health care quality standards. If your care did not meet these standards, we work closely with the doctor and the place where you received care so they can find a way to do a better job in the future.

When a concern is found, Stratis Health does more work to learn why it happened, and to help prevent it from happening again. We may:

• Educate the doctor or health care facility about ways they can improve care
• Help the doctor or health care facility make a plan to improve care in the future
• Send your concerns to other agencies or licensing boards as necessary

Are You Aware of Your Medicare Rights? This document summarizes who to contact in Minnesota for quality of care concerns and how to appeal a discharge or denial of coverage. (1-page PDF)