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 over 35 years experience in conducting medical case review, determining 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 together 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:
- Discuss your concerns with the facility and/or physician providing your treatment. Most facilities have patient relations staff who can assist you in resolving your concerns. They are best situated to fully understand your situation and address your concerns.
- If Step 1 is not possible or does not achieve the desired results, and your concern is a quality-of-care concern for services paid by Medicare, call the Stratis Health Medicare Helpline toll free at 1-800-444-3423 (TTY: 1-800-627-3529). A trained staff member will listen to you and inform you of your options, including:
- File a complaint/medical record review
- Alternative dispute resolution/mediation
- If your concern does not fall with Stratis Health’s scope of service, see the list of additional resources to help you determine the appropriate organization to contact for assistance.
Can Stratis Health review your concern?
We respond to beneficiary concerns and complaints by reviewing the related medical records. Medicare directs Stratis Health to use only the medical record to make a decision about health care quality concerns. We cannot examine patients or visit health care facilities.
Examples of what we can review:
- Medication mistakes
- Unneeded or inappropriate medical care
- Delay in medical treatment
- Lack of or incomplete discharge instructions, or other instructions related to your medical care
- Unexpected complications as a result of the medical care you received
Examples of what we cannot review:
- Non-medical concerns such as cold food, cleanliness of your room, etc.
- Conversations between yourself or your family and the medical staff or physician
- Concerns regarding billing or coverage
- Pictures, tape recordings, CDs, etc.
Stratis Health’s review process is based only on information actually written in your medial record. If your concern is not documented in the medical record, we do not have the information to be able to make a decision about it. This does not mean that we do not believe you, or that we think your concern is not important. It just means that there has to be documentation so we can make a decision.
How long does a review take?
Once Stratis Health receives your written complaint, a review begins. The entire process can take up to six months to complete.
Health care providers are allowed certain amounts of time to copy and send us your medical record, a timeframe for the review is directed by Medicare. Extra time may be needed if we request more information about your care. Also, your medical record may be reviewed by more than one physician and may be reviewed more than one time. We know you are seeking answers and realize that the wait during this complicated process can feel long. To keep you up-to-date on the review, we stay in regular contact with you throughout the process.
File a complaint/medical record review
The QIO review is not meant to punish doctors or the place where they provide care. The purpose of the review is to help health care providers improve the care they give to their Medicare patients.
The lessons from the case review are applied to developing 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
- If you decide to make a formal complaint, call Stratis Health’s Helpline for further information. We will send a packet of information, including a Request for Review form. Once we receive the written complaint and signed Medicare Quality of Care Complaint Form, the quality of care review will begin.
- A Stratis Health case review manager will contact you once the complaint is filed and will keep you updated about the review, by phone, and/or by mail.
- We will request a copy of your medical record(s) from any physician, 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.
- A physician 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 all 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 in the letter. The law also gives your doctor the right to 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
Alternative dispute resolution/mediation
The Medicare Program has found that many patients have concerns about the quality of their care from a doctor, hospital, nursing home, or other health care provider. However, when a QIO reviews the medical records sometimes we find that care delivery met all of the standards.
If you are dissatisfied with your care even though it met quality standards, the problem may be related to poor communication or a misunderstanding between the patient/family and the health care provider. These types of situations are ideal for mediation. Mediation brings together the health care provider and the Medicare consumer (or representative) for a face-to-face meeting, which is led by a neutral professional mediator. Mediation is a good way to discuss your concerns and may give closure to an upsetting event.
Not all complaints are appropriate for mediation, and you and your doctor or provider representative must agree to participate in mediation before moving forward.
Participants often report improved relationships after the mediation session. If your doctor or provider agrees to participate, he/she is also committed to improving communication.
Call the Stratis Health Medicare Helpline toll free at 1-800-444-3423 (TTY: 1-800-627-3529) to see if your concern is appropriate for mediation.
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