FREQUENTLY ASKED QUESTIONS


Frequently Asked Questions (FAQ) for Medicare Beneficiaries:
What to do if you have a concern regarding care you
received while on Medicare

What is a Medicare Quality Improvement Organization (QIO)?
A Quality Improvement Organization (QIO) consists of groups of doctors and health care experts to check on and improve the care given to people with Medicare. QIOs work under the direction of the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. There are 53 QIOs responsible for each U.S. state, territory and the District of Columbia.

How do I contact my QIO?
To get the address and phone number of the QIO for your state or territory:
• Visit www.ahqa.org on the web and click on “QIO Locator.”
• Go to the Helpful Contacts section of this website
• Or, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

What can a QIO do if I have a concern regarding care I received while on Medicare?
One of the responsibilities of QIOs is to look at the quality of medical care that Medicare patients receive. The QIO’s goal is to address your concerns while working with doctors and health care providers (hospitals, nursing homes, surgery centers, etc.) to help them provide better care in the future. Your QIO will help you complete paperwork about your concerns so that your complaint can be considered.

What concerns can my QIO address?
Examples of quality of care concerns that your QIO can address are:
• Medication errors
• Unnecessary or inappropriate surgery or treatment
• Your condition changed and was not treated
• Discharged from the hospital too soon
• Incomplete discharge instructions and/or arrangements

What will happen after I contact my QIO?
If you make a quality of care complaint, your QIO will request your medical records and forward them to a practicing doctor who works with the QIO. This doctor will review the medical records and look at all aspects of the care you received. Depending on the doctor’s findings, the QIO will decide how your complaint can or should be addressed.

What is medical record review?
Medical record review is when your doctor or health care provider mails the QIO a copy for a doctor working with the QIO to review.

For concerns that are not documented in the medical record, the QIO can not make a decision one way or the other. This does not mean the QIO believes the things that you are concerned about did not happen. It just means that there is nothing in the record about them that would allow it to make a determination. A delay in bringing your pain medication, for example, might not be documented in the medical record. For concerns that are not documented in the medical record, the QIO can assist you with contacting other agencies that can address your concern.

What will happen after my QIO reviews my medical record?

The QIO will tell you if the care you received met professionally recognized standards of health care. The QIO is limited by federal law as to what it can tell you beyond this. If your care didn’t meet these standards, the QIO will work closely with the doctor or health care provider to improve future care.

If the care you received did meet professionally recognized standards, the QIO can explore other methods to resolve your complaint. The QIO may also work with the doctor or provider to help them improve the care they provide.

What will happen to my doctor if my QIO finds that the care I received did not meet professionally recognized standards?

The purpose of the QIO review is to help doctors and health care providers improve the future care they give to people with Medicare. The purpose isn’t to punish the doctor or provider. When the QIO reviews a complaint, it takes steps to find out what caused the complaint to prevent it from happening again. The QIO may:
• Educate the doctor or provider on ways they can improve.
• Help the doctor or provider to develop a plan to improve future care.
• Send the QIO’s concerns to the proper state agency.
• Examine more medical records to see if there are other concerns.

What other methods might my QIO offer to resolve my complaint?
Other methods, know as dispute resolution, if appropriate for your situation, allow you to work with the QIO to report the circumstances of your complaint to the appropriate physician or health care provider so that they can make improvements.

What is mediation?
Mediation is one form of dispute resolution that may be an option for you. Mediation is a face-to-face, confidential meeting between the two sides (parties) of a conflict, for example, you and your doctor or health care provider. A mediator is an impartial third party who has no interest in the outcome of the problem and helps guide the two parties to a resolution.

What other forms of dispute resolution are available?
Other forms of dispute resolution might be less formal than mediation. For example, a mediator may talk to each party separately to resolve the conflict. This is known as facilitated resolution. The goal of facilitated resolution is to help guide the two parties to a resolution. The difference is that with facilitated resolution you would not speak directly with the doctor or provider.

Where can I get help if I have a concern about a physician?
If you have a concern about a doctor, such as unprofessional conduct, incompetent practice or licensing questions, you may contact your state medical board.

Where can I get help if I have a concern about conditions at a hospital?
If you have a concern about conditions at a hospital, such as rooms too hot or cold, cold food, or poor housekeeping, you may contact your state department of health services.

Where can I get help if I have a concern about the quality of care for services not covered by Medicare?
If you have a concern about the quality of care for services that Medicare doesn’t cover, such as services in a nursing home, assisted living facility, adult day care, or hospice agency not related to quality of care, contact your state department of aging.

Where can I get help if I have a concern about billing?
If you have a concern about billing, such as questions about charges and what Medicare does or does not cover, contact 1-800-MEDICARE.