2006 - 01 Spring Issue

IN THIS ISSUE

Use Your Medicaid Rights
Beneficiary Complaints Involving Prescription Drugs
From a Doctor's Point of View
Calling IPRO?
Important Telephone Numbers

Use your Medicare Rights

As a Medicare beneficiary, you have guaranteed rights. These rights apply to people in the traditional Medicare program as well as those in Medicare Advantage Plans. It is important to know your rights, and how to use them. In this issue of Healthy Seniors, we will look at your right to receive QUALITY health care services.

Q: What should I do if I have concerns about the quality of care I received?

A: If you have concerns about the quality of care you received from a Medicare provider, you have the right to file a complaint. For help, call IPRO's Beneficiary Complaint Response Program. The number to call is 1-800-331-7767, extension 464. You may also call 1-800-MEDICARE (1-800-633-4227).

Q: What is a quality of care concern?

A: Quality of care concerns may include, but are not limited to, any one of the following examples:

You think you may have received the wrong medication.
You believe you received incorrect treatment for a new or old condition.
You think your health care provider or physician did not give you proper care instructions.

You may submit "quality of care" concerns or complaints like these to Medicare or to IPRO.

Q: How does IPRO follow up on my complaint?

A: Your written quality of care complaint enters the Beneficiary Complaint Response Program for case review. Physicians and nurses at IPRO review medical record information related to the services that are the subject of the complaint. You and the provider of the services are notified as to whether the care you received met or did not meet the "Professionally Recognized Standard of Care" (PRSC).

Q: How do I ask for help with my "quality of care" concern?

A: You can call Medicare. The number to call is 1-800-MEDICARE (1-800-633-4227). If your care is covered under Medicare, a Medicare representative will put you in touch with the Quality Improvement Organization (QIO) in your state. In New York, this is IPRO.

You may also call IPRO directly. IPRO has a toll free helpline number and nurse case managers who can help you decide if you have a quality of care concern for us to review. The number to call is 1-800-331-7767, extension 464.

IPRO has nurse case managers who will help you write your complaint and explain the process to you. All complaints must be in writing. We will help you write the complaint if you are unable to do it. We will help you with the paperwork and tell you what you can expect from us as the QIO reviewing your case.

Q: If I report my quality of care concern to Medicare, will it interfere with my benefits?

A: No. Medicare has provided you with Medicare rights and wants you to know them and use them. You have the right to contact Medicare if you have questions about the care you have received. They also want you to know that the review process at IPRO is available to help with your quality of care concerns.

Q: What kind of process does IPRO use to address my complaint?

A: When we receive your written complaint and your permission to proceed, IPRO will ask your physician or health care facility to mail us a copy of your records. Our review is limited to what is written in your medical record. However, it is important for you to know that the IPRO physician reviewers selected to review your case will not have a relationship with your physicians or the health care facility where you received your care.

Our expert physician reviewers will review your medical records and your complaint to determine if the care you received met the professionally recognized standard of care. If our physicians decide that the care you received met the professionally recognized standard of care, we will contact you with a final letter and close the case.

If our first physician reviewer determines that there are issues that need to be explained, we will need to obtain more information from your physician or provider to help our physician reviewer make a determination. We may also seek another opinion from another physician reviewer. This will extend the review process until a final determination is made and you receive a letter of the outcome.

Your nurse case manager will help you at the start of the process, and keep you updated throughout the process. You will also have her telephone number to call at any time if you have questions.

Q. Will I find out what the physician, hospital or health care facility did wrong, or what their mistakes were?

A: We may only be able to tell you that the care you received did or did not meet the professionally recognized standard of care. If the care you received did not meet the standard, we would work closely with the physician or facility to prevent it from happening again. Federal law limits what we are able to tell you beyond this. The law gives the physician a right to limit what information we may share with you. Here are some examples of what you may expect to see in our final letter to you:

If our physician determines that care did not meet the professionally recognized standard of care, your letter may read like this:
After a thorough review of your medical records and any additional information provided by the physician/facility, we determined that the services you received did not meet professionally recognized standards of health care. We share your concern about the quality of services you received and have initiated appropriate actions as warranted by our review findings.

We may also include a summary of the review if your physician agrees to the release of the findings. If not, you can expect to see the following statement:
Consent to release detailed information was not granted.

If there was no evidence supporting your concern in the medical record, your letter may sound like this:
After a thorough review of your medical records and any additional information provided by the physician/facility, we determined that the services you received met professionally recognized standards of health care.

Q: What do you mean when you say that care did not meet the professionally recognized standard of care?

A: "Professionally recognized standard of care" means that the health care you received for your medical problem was consistent with that provided by your physician's peers under similar circumstances. A bad outcome may or may not reflect substandard care. For example, if there are known complications or risks associated with your condition or procedure, even care that meets the "professionally recognized standard of care" could result in a bad outcome.

Q: Does Medicare have any other ways to help resolve my quality of care concerns?

A: Yes. If our physician reviewer determines that your care met the professionally recognized standard of care, you may be offered an opportunity to participate in an Alternate Dispute Resolution (ADR) program. IPRO has two ADR programs: Mediation and Alternate Approach Improvement Methodology (also known as AAIM). One of these programs would be offered to you on a voluntary basis.

Mediation involves all the parties (the beneficiary filing the complaint, the involved physician and/or the health care facility) in a face-to-face meeting. A neutral third party, called the Mediator, leads the meeting. Mediation is a good way to discuss all concerns and provides you with direct involvement in having your concerns discussed.

Alternate Approach Improvement Methodology (AAIM) differs from Mediation. When your case is being handled this way, an IPRO facilitator will take your concerns to the involved physician/facility for you. The AAIM program allows you to be involved in resolving your concerns without having to leave your home, or meet with the other parties face to face. All communication is between you and the IPRO facilitator; you don't discuss anything with the involved physician or facility. Our facilitator will provide you with updates each time the facilitator speaks with the involved physician or facility until the case is resolved and closed.

Mediation and AAIM provide an alternative way to resolve your concerns about quality of care issues that were not supported by our physician's review of the medical record. They provide you with a resolution and improve the quality of care delivered to other people in similar situations.

If you have questions about your rights under Medicare, please call the Medicare hot line at 1-800-MEDICARE (1-800-633-4227).You may also contact IPRO's Medicare Beneficiary Complaint Department directly at 1-800-331-7767, extension 464.

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Beneficiary Complaints Involving Prescription Drugs

The Medicare Part D Pharmacy Benefit

Medicare began paying for prescription drugs for beneficiaries on January 1, 2006. This prescription drug benefit is also known as "Medicare Part D."

IPRO, as the Medicare Quality Improvement Organization for New York State, is responsible for reviewing written complaints about the quality of care or services provided to Medicare beneficiaries in all kinds of settings. That responsibility includes reviewing beneficiary complaints about Medicare Part D (pharmacy) services.

Here are some examples of the kinds of complaints related to the new benefit that IPRO could help to resolve:

You believe that your doctor gave you misleading or incorrect medical information about the medicines you take.
You experienced an allergic reaction to a drug that was prescribed for you, even though the family member who accompanied you to the doctor told the doctor that you had a bad reaction to that medicine in the past.
You think you received incorrect medical information from a representative of a pharmacy plan's Medication Therapy Management Program.
You believe that your medications were inappropriately changed after receiving Medication Therapy Management Program services.

Remember, if you have quality of care concerns or complaints about your prescription drugs, you have the right to complain. Call 1-800-MEDICARE (1-800-633-4227) or IPRO directly at 1-800-331-7767, extension 464.

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From a Doctor's Point of View

by Monty M. Bodenheimer, M.D., IPRO Medical Director

Physicians and health care professionals strive to provide optimal care. At times, however, you or a loved one may still have experienced frustration or feel dissatisfied about the quality of your care. If you or someone you know has concerns about the quality of care you have received, we encourage you to submit these concerns to IPRO, the Medicare Quality Improvement Organization (QIO) for New York State.

Helping us help you improves the quality of care for Medicare Beneficiaries, one person at a time.

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Calling IPRO?

Please have this information available when you call:

Beneficiary's Name
Your Name and Relationship to the Beneficiary (if you are not the beneficiary)
Beneficiary's Medicare Number and Date of Birth
Beneficiary's Address
Effective Date on the Notice
Telephone Number including area code, where IPRO can contact you
Name of the Provider or Facility
Telephone Number, including area code, of the Provider or Facility

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Important Telephone Numbers

Quality of Care.
Report quality of care concerns to the IPRO Beneficiary Complaint Response Program. The number to call is 1-800-331-7767, extension 464.

Hospital Services.
If you think you are being discharged from the hospital 1-800-446-2447.

Non-Hospital Services.
- Traditional Medicare. If you receive a Notice of Medicare Provider Non-Coverage call 1-800-833-0356 (TTY 866-466-3507). Ask for an Expedited Determination of your case.
- Medicare Advantage. If you receive a Notice of Medicare Non-Coverage call 1-888-696-9561 (TTY 866-446-3507). Ask for a Fast Track Appeal.

Telephone lines are open seven days a week from 8:30 am to 4:30 pm, even on Saturday, Sunday, and holidays.

Other Questions

For answers to general benefit questions or other Medicare inquiries, call 1-800-MEDICARE (1-800-633-4227) TTY/TDD (1-877-486-2048) or, visit Medicare's Web site, www.medicare.gov.

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