Dear Marci,
I have arthritis, and I recently went to my doctor to talk about some new symptoms I’ve been experiencing. In my opinion, my doctor does not take my concerns seriously, and I’m worried about the quality of care I am receiving. What can I do?
-Enid (Newark, NJ)
Dear Enid,
If you have a concern about the quality of care you receive from a Medicare provider, your concern can be handled by the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) for your area. The BFCC-QIOs are made up of practicing doctors and other health care experts. Their role is to monitor and improve the care given to Medicare enrollees. BFCC-QIOs review complaints about the quality of care provided by:
- Physicians
- Inpatient hospitals
- Hospital outpatient departments
- Hospital emergency rooms
- Skilled nursing facilities (SNFs)
- Home health agencies (HHAs)
- Ambulatory surgery centers
Examples of situations that you might wish to file a quality of care complaint about include:
- A medication mistake
- Picking up an infection during a stay in a facility
- Receiving the wrong care or treatment
- Running into barriers to receiving care
Two ways that the BFCC-QIO might review this complaint are:
- Immediate advocacy: Immediate advocacy is an informal process used by the BFCC-QIO to quickly resolve a concern or complaint. This process starts when you, a family member, or an advocate gives the BFCC-QIO permission to address the concern or complaint. The BFCC-QIO will then contact your provider. If your provider agrees to participate in the resolution of the issue, the BFCC-QIO will work with both you and your provider to resolve the issue. If your provider declines to participate, you will be able to file a written complaint. Immediate advocacy can take place when the complaint is unrelated to the clinical quality of health care, or when it is related to the clinical quality of health care, but does not rise to the level of being a significant quality of care concern. For example, immediate advocacy could be used to address complaints about a hospital staff’s poor communication. In cases when immediate advocacy is used, the issue should be resolved within no more than two business days. This process is not available if you wish to remain anonymous.
- Quality of care complaints: If you have concerns related to the quality of clinical care that you have received, you can file a complaint with the BFCC-QIO so they can review the case. You can do this by calling your QIO or submitting a written complaint. When the BFCC-QIO gets your complaint, they should call you to ask clarifying questions about your complaint and to get the contact information for your provider. A physician of matching specialty will review the medical record to determine whether the care provided met the medical standard of care, or whether the standard of care was not met. The review process can take up to a few months, and when the review is over, you and your doctor will be notified by phone and in writing.
Livanta and KEPRO are currently the two BFCC-QIOs that serve the entire country. To find out which BFCC-QIO serves your state or territory and how to contact them, visit www.qioprogram.org/contact or call 1-800-MEDICARE.
If you have a Medicare Advantage Plan, you can choose to make complaints about the quality of care you receive through your plan’s grievance process, through the BFCC-QIO, or both. If you file a grievance with your plan about the quality of care you receive, the plan should inform you of your right to file a complaint with the BFCC-QIO.
-Marci
