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Complaint and Mediation Program
Mediation and facilitated resolution are two voluntary options offered by Medicare to resolve quality of care complaints. There is no charge for either service. A Masspro physician reviewer determines if your complaint is appropriate for either of these alternatives to medical record review. Mediation and facilitated resolution can be very helpful in resolving complaints that involve poor communication or misunderstandings between a beneficiary and their healthcare provider.
Mediation brings together a healthcare provider and a patient (or his/her authorized representative) for a face-to-face meeting facilitated by an impartial, trained mediator.
Facilitated resolution uses professionals from the state's Quality Improvement Organization (QIO), in this case Masspro, as a "go-between" to communicate your concerns to your healthcare provider.
Medicare beneficiaries have certain rights and protections, an important one being the right to quality care. Beneficiaries who have a concern or are not satisfied with their care can follow the steps below. Masspro can review care provided by doctors, nurse practitioners, physician’s assistants, hospitals, emergency rooms, hospital outpatient departments, home health agencies, hospice agencies, skilled nursing facilities, ambulatory surgical centers, and Medicare Health Plans.
Examples of Quality of Care Issues
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Delay in health care services
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Treatment that was not ordered, or other unnecessary care
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A change in condition that was not properly evaluated and/or treated
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Poor care by a provider or facility
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Medication issues: wrong medication, overdose, missed dose, administration errors, etc.
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Call Masspro’s helpline at 1-800-252-5533, or 1-800-MEDICARE (800-633-4227). A trained staff member will listen to you and inform you of your options. Your case may be suitable for mediation, a free service coordinated by Masspro.
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If you decide to make a formal complaint, Masspro can help you put it in writing. Once we receive the written complaint, the quality of care review will begin.
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You can file a complaint anonymously. However, at the end of Masspro’s review, you will only receive a letter that informs you that the review is complete.
A Masspro review case manager will contact you once the complaint is filed and serve as your contact throughout the process.
Masspro will request your medical record. The record review helps Masspro decide whether standard guidelines or expected practices were followed by the health care provider. A nurse and physician reviewer team reviews the care that was provided and makes an initial finding. Masspro informs the provider about the results of the complaint review, and gives the provider a chance to comment.
At the end of the review, we send you or your authorized representative a letter describing the results of the review. The letter may include a summary of our findings and information on how we plan to work with the provider or facility to improve future care. Please note that Masspro may only be able to report whether the care received met professionally recognized standards of health care.
After our review, we work with providers so that they can give better care in the future.
Masspro wants to make sure that every Massachusetts health care provider gives Medicare beneficiaries medical care that meets professional standards. Each complaint that is reported to us is an opportunity to improve the health care given to other Medicare beneficiaries.
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