beneficiary protection
Appeals
Under the Beneficiary Protection Program, Medicare beneficiaries have the right to appeal decisions to end their Medicare-covered services in both hospital and non-hospital (nursing home, home health, hospice) settings. Masspro is responsible for reviewing the beneficiary’s medical record to provide an objective determination of whether services have ended prematurely.
Fee-For-Service (i.e., original Medicare) Medicare beneficiaries can appeal two types of notices: the “Notice of Medicare Provider Non-Coverage,” which applies to the nursing home, home health, and hospice settings.
Beneficiaries enrolled in a Medicare Advantage plan or other Medicare health plan that is not fee-for-service, can also appeal the “Notice of Medicare Non-Coverage,” which applies to the nursing home or home health settings. Medicare beneficiaries have the right to appeal a discharge decision from an inpatient hospital admission.
Quality of Care Complaints
Medicare beneficiaries have rights and protections, especially the right to quality health care. Beneficiaries who have a concern or are not satisfied with their care can file a complaint with Masspro. Examples of quality of care issues include service delay, omission of treatment, the provision of unnecessary care, and medication issues.
After a complaint is filed, a physician/nurse review team examines the care provided and makes an initial finding regarding whether standard guidelines or expected practices were followed. The provider is then informed about the results of the complaint review, and given the chance to comment. If indicated, Masspro staff members work with providers to improve care.
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