General Quality of Care Review: Source – Anonymous Beneficiary

5080 – General Quality of Care Review: Source – Anonymous Beneficiary (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) If a beneficiary wishes to remain anonymous, the QIO must process the complaint as a General Quality of Care Review if the QIO believes the concerns warrant review. (See §5100, 42 CFR §§476.120(a)(2), and 476.160(a)(1)(i)). For General Quality of Care Reviews conducted as a result of a beneficiary complaint or referral, the beneficiary should be informed that the QIO will NOT inform the practitioner/provider: 1. Of the source of the referral for the Review; and 2. That the QIO is requesting medical records as a result of a beneficiary complaint/referral. For General Quality of Care Reviews conducted as a result of a beneficiary complaint or referral, the QIO should inform the beneficiary that she/he will NOT be informed of the results of the General Quality of Care Review. If the individual making the complaint is identifiable as a beneficiary or beneficiary representative, the QIO is able to initiate direct contact with the beneficiary or beneficiary representative. If the beneficiary does NOT wish to remain anonymous, the QIO shall process the case in accordance with the Beneficiary Complaint Review procedures. (See §5040). A QIO should make every effort to keep the beneficiary’s name confidential during the review process if a General Quality of Care Review is initiated. This includes taking steps that will not alert the practitioner/provider to this specific beneficiary. For example: • If additional medical records are needed from the practitioner/provider to complete other case reviews, the medical request for all records should be issued at the same time. This will minimize the practitioner’s ability to ascertain the name of the particular beneficiary that initiated the Quality of Care Review by the QIO. NOTE: The QIO should inform the beneficiary of the possibility the practitioner/provider could ascertain the name of the beneficiary during the General Quality of Care Review process based on the nature of and the specific facts surrounding the beneficiary’s complaint.