Organization of Chapter

5015 – Organization of Chapter (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) The chapter is organized based on the two types of Quality of Care Reviews that QIOs conduct; Beneficiary Complaint Reviews are addressed first (See §§5025-5065), followed by General Quality of Care Reviews. (See §§5100-5125.) NOTE: All references to a beneficiary in this chapter also include the beneficiary representative, unless otherwise indicated. Review Type and Description 1. Beneficiary Quality of Care Complaints – Reviews initiated because a beneficiary or the beneficiary’s representative has complained (referred to as Beneficiary Complaint Review) about the quality of care rendered to a Medicare beneficiary 2. General Quality of Care Reviews – Reviews conducted because the QIO has independently identified a potential quality issue or has been referred a quality issue from another entity (referred to as General Quality of Care Review) Sources for Reviews A. Beneficiary Complaint Review Sources 1. A written complaint filed by a beneficiary 2. A oral complaint by a beneficiary where the beneficiary agrees to participate in Immediate Advocacy B. General Quality of Care Reviews Sources 1. Concerns Identified during Other Review Activities: A Quality of Care review conducted when a potential quality of care concern(s) is identified during the course of any other review activity, such as medical necessity reviews, expedited discharge appeals, Emergency Medical Treatment and Labor Act (EMTALA) reviews. 2. When a beneficiary raises a concern, but the beneficiary declines to submit a formal written complaint, and the QIO makes a preliminary determination that the complaint involves a potential gross and flagrant, substantial, or significant quality of care concern, such complaint may be processed as a General Quality of Care Review. For purposes of 42 CFR §476.120(a)(1) and this provision, an anonymous complaint, even if received in writing, is not a “written complaint” sufficient to trigger the beneficiary complaint procedures outlined in 42 CFR §476.130. 3. Referrals include a Quality of Care Review conducted in response to referrals from other entities (e.g., Medicare Administrative Contractors, State-based organizations, the Office of Inspector General, the Office for Civil Rights), including anonymous referrals. 4. Tracking and Trending is a Quality of Care review conducted as a result of tracking and trending or other analysis of data. Stages of Review by Type Beneficiary Complaint Reviews The process steps for this review are separated into four stages to facilitate identification of roles and steps associated with various aspects of the process: Stage 1: Intake Stage; Stage 2: Quality of Care Review Stage; Stage 3: Opportunity for Discussion Stage; and Stage 4: Reconsideration Stage. NOTE: The Social Security Act §1154(a)(14) requires that QIOs conduct an “appropriate review of all written complaints” from Medicare beneficiaries alleging that the quality of services they received did not meet professionally recognized standards of care. For Beneficiary Complaints, the process instructions include a QIO’s authority to offer Immediate Advocacy (See §5035) during the Intake Stage if a written complaint has not yet been received. QIOs may also offer at their discretion a Post-Peer Review alternative dispute resolution process, called Post- Review Advocacy (See §5065), for complaints submitted in writing that Peer Reviewers determine contain no significant quality of care concerns. General Quality of Care Reviews The process steps for this review are separated into these three stages to facilitate identification of roles and steps associated with various aspects of the process: Stage 1: Intake Stage; Stage 2: Quality of Care Review Stage; and Stage 3: Reconsideration Stage.