HI 00208.045 Complaints Against Providers

A. General

Medical facilities are required to meet certain established standards in order to participate under Medicare. State agencies are responsible for conducting the certification and recertification surveys to determine initial and continuing compliance with the conditions of participation (see HI 00208.075). For nonparticipating providers, various licensing and other regulatory requirements are enforced by the individual States.

B. DO responsibility

DO’s are neither equipped nor assigned the responsibility to deal with the certification or licensing process; however, in the course of their regular business they visit medical facilities which may or may not be certified under title XVIII.

All DO employees should be alert to and report to the HSQ RO obvious substandard conditions in all medical facilities (participating and non-participating providers), whether brought to their attention by personal observation or through complaints by the public.

Reports of substandard conditions in facilities participating under Medicare should be made promptly, sending a Health Facility Complaint Memorandum (see C. below, and HI 00208.050) to the HSQ RO, with a copy to AC Field when there are apparent difficulties in the facility. The HSQ regional staff will either investigate or refer the complaint to the appropriate State agency responsible for certification and licensing. The HSQ RO will periodically report back to DO’s on the positive results of their referrals.

Matters relating to billing, reimbursement, etc. should be reported to the CMS RO.

C. Preparation of the Health Facility Complaint Memorandum

Prepare the form in quadruplicate (as well as any attachments), to report complaints of substandard conditions. The appropriate conditions are prescribed in regulations dealing with the various types of providers, and are available to the DO. The information contained in the memorandum must be as specific as possible. This will ensure a more productive investigation.

Complaints concerning the treatment received by an individual patient can best be resolved if specific information is available, e.g., name, claim number, date of occurrence, names of those involved, and actions taken by the complainant to resolve the issue. Indicate if the complaint has brought the situation to the attention of the facility or any other government agency.

In all instances be sure to attach whatever material is available to document the complaint. This includes bills, receipts, or notices of any kind (including utilization review notices). Send three copies of the memorandum (and attachments) to the Health Standards and Quality Bureau. Send one copy to the AC Field. DO retention of material will be determined by regional and local guidelines.

Except when regional instructions indicate otherwise, before a complaint is referred to the HSQ RO, it should be reviewed by someone designated by management to screen out complaints which do not require a referral for investigation.

Complaints which need not be referred include events which occurred more than one year ago; complaints from the same person which duplicate previously submitted complaints; situations involving only an explanation of some routine aspect of the Medicare law; appeals which should be properly disposed of through the appeals process; and those situations which generally do not affect either the health or safety of the patient.

If, after considering the above and exercising judgment as to whether the circumstances represent a bona fide complaint, the DO is undecided, but feels that there may be reason to doubt the validity of the complaint, forward it to the HSQ RO with an RC explaining the basis for the DO doubts. The RC will assist the RO in deciding whether to forward the complaint for investigation. If the complaint is forwarded, the DO assessment will help decide the timing of the investigation.

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HI 00208.045 - Complaints Against Providers - 09/12/2003
Batch run: 04/07/2015