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OIG says medicare complaint process needs drastic improvement - Updata - Health and Human Services Office of Inspector General - Brief Article

Healthcare Financial Management, Oct, 2001

The Medicare beneficiary complaint process, a statutory responsibility of Medicare peer review organizations (PROs), is significantly flawed, the HHS Office of Inspector General (OIG) found in a report issued in August 2001. The OIG's report notes that beneficiary complaints can expose serious instances of substandard care, and that problems in the complaint, process therefore may allow dangerous practices or situations to continue.

The recent report is not the first in which the OIG has identified flaws in the PROs' beneficiary complaint process. In a 1995 report, the OIG found that Federal confidentiality regulations precluded PROs from responding to complaints in a meaningful way, that PROs received too few complaints to identify patterns of poor care, and that the complaint process was too lengthy.

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The Centers for Medicare and Medicaid Services (CMS--formerly HCFA) responded positively to the OIG's 1995 findings and attempted to make appropriate changes. However, the OIG's 2001 report found that little has improved over the past five years and that the process continues to be an ineffective safety valve for Medicare beneficiaries.

As a basis for its recent report, the OIG used a template it developed following issuance of its 1995 report outlining eight criteria of an effective complaint process. The criteria are:

* Accessibility--the process is widely known and easy to use;

* Investigative capacity--the process involves the appropriate experts, resources, and methods to assess complaints and determine whether they reflect an underlying pattern;

* Interventions and follow-through--the process triggers appropriate interventions and monitoring based on substantiated complaints;

* Quality-improvement orientation--the process guides quality improvement;

* Responsiveness--the process routinely provides consistent, clear, and substantive responses to complaints;

* Timeliness--each process step is completed within a reasonable, established time frame, and mechanisms exist to deal quickly with complaints of an emergency nature requiring immediate attention;

* Objectivity--the process is unbiased, balancing the rights of each party; and

* Public accountability--the process makes complaint information available to the public.

The OIG found that the only criterion adequately reflected in the PROs' beneficiary complaint process is objectivity. Further, the OIG identified two significant obstacles to establishing a more effective beneficiary complaint process. First, CMS's contracts with PROs focus primarily on quality improvement and payment error reduction and treat the complaint process as a minor issue relegated to the category of "other contract activities." Second, PROs tend to orient themselves more to the medical community than to the beneficiary community, and thus are less inclined to address beneficiaries' concerns.

The OIG's recent report recommends that CMS revise the beneficiary complaint process to meet all eight criteria identified in the template, which CMS already has endorsed. The OIG offers CMS two options to consider in achieving an effective complaint process: revise the existing process by making substantial improvements and changes, or establish a new complaint process outside of the PRO program. The latter option would require legislative change.

As of September 7, CMS had not yet responded to the OIG's report. To read the report, The Medicare Beneficiary Complaint Process: A Rusty Safety Valve, go to http://www.hhs.gov/oig/oei/reports/a535.pdf.>