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If you’re a Medicare beneficiary or caring for someone who’s on Medicare, you may at times ask yourself, “Who do I call to report a quality of care concern?”  Problems can come up wherever health care providers interact with patients including hospitals, nursing facilities, doctors’ offices and at home. Generally, Medicare beneficiaries can use two procedures—one at the federal level and the other at the state level—to report quality of care concerns. That’s because federal and state authorities share responsibility for promoting health care that meets certain standards.

Under federal law, any health care practitioner or provider who receives Medicare or Medicaid funds must ensure that their services are “of a quality that meets professionally recognized standards of care.” The law authorizes an organization called the Beneficiary and Family Care Centered Quality Improvement Organization (BFCC-QIO) to determine if a health care provider’s services meet those standards. The BFCC-QIO’s goal as a Medicare contractor is to improve care for all Medicare patients. Thus, it emphasizes education and practice improvement measures, not punishment, for providers who fail to meet recognized standards of care. The BFCC-QIOs often help hospitals for example, to improve flawed systems that get in the way of providing good care. As a Medicare beneficiary, you or your representative can call the BFCC-QIO for your state to complain when services given by physicians, physician assistants, interns, nurses, physical therapists, durable medical equipment providers, and others don’t measure up to your expectations.

State licensing boards are not tied directly to Medicare and, unlike the BFCC-QIOs, can sanction providers by restricting or revoking their licenses to practice. All states have licensing boards that oversee the activities of physicians, nurses, pharmacists, dentists, and other health professions. These boards operate under state practice acts that give them power to regulate the activities of specific health professions or occupations with rules for education thresholds, licensing examinations, continuing education, and conduct. The number of health regulatory boards varies from state to another, but one thing they all have in common is the authority to discipline licensees for unprofessional conduct.

Failure to meet accepted standards of care is one example of misconduct that’s subject to disciplinary action by a board. Other examples of unprofessional conduct include:

  • Alcohol and substance abuse

  • Sexual misconduct

  • Neglect of a patient

  • Prescribing drugs in excess or without a legitimate reason

State licensing boards review and investigate complaints from Medicare beneficiaries and other patients. Complaint filing procedures vary from board to board, though it’s common to require complaints to be in writing. Some states protect the confidentiality of complaining parties while others allow the accused health care provider to learn their identify. Some boards simplify the process by offering complaint portals on their websites through which you can download and mail a hard copy of a complaint form, or complete and quickly submit an online form.

Your state SHIP program can help assess quality of care concerns and decide how to proceed. Sometimes it’s not clear if a concern should go to the BFCC-QIO, a licensing board, or to someone who can handle customer service and billing concerns.  SHIPs can help you sort it out.

 

Mike Klug, Medicare Consultant