Aging Health Matters
This podcast will cover topics of interest to people who have Medicare. Episodes will include Medicare rights and health care. We hope you tune in for helpful tips that can improve the healthcare journey of you or someone you know.
Kepro is now Acentra Health.
All future podcast episodes will say "Acentra Health" - while older episodes (those posted prior to July 1, 2024) will refer to "Kepro." Rest assured, that all content about our free services for people who have Medicare are accurate. Our name has changed, but our services remain exactly the same.
Acentra Health is a Beneficiary and Family Centered Care Quality Improvement Organization, also referred to as a BFCC-QIO.
For more information about Acentra Health, please visit www.acentraqio.com.
Aging Health Matters
Learn About Acentra Health’s Beneficiary Complaint Process
As a contractor for Medicare, Acentra Health serves as the Beneficiary and Family Centered Care Quality Improvement Organization, also referred to as a BFCC-QIO. While Acentra Health provides BFCC-QIO services in 29 states, the general information is relevant to everyone who has Medicare (including Medicare Advantage) and everyone who works with people who have Medicare.
This episode has our Operations Manager, Carla Boguslawski, MBA, MEd, BS, and Melinda Burk, LPN, Clinical Review Nurse, discussing the options related to filing a beneficiary complaint with Acentra Health.
For more information about Acentra Health BFCC-QIO, please visit www.acentraqio.com.
KEY TOPICS
00:21: Overview
01:42: What is a beneficiary complaint?
02:55: What is a medical record review?
03:41: What cannot be reviewed?
06:06: How to file a complaint
08:11: Final thoughts
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Subscribe to our newsletters: Case Review Connections, On the Healthcare Front at www.acentraqio.com
RESOURCES
BFCC-QIO Information for stakeholders: www.acentraqio.com/partners
BFCC-QIO Information for people who have Medicare: www.acentraqio.com/bene
BFCC-QIO Information to file a complaint and to get forms and resources: www.acentraqio.com/bene/qualityofcarecomp/
Medicare – www.medicare.gov
Our address is 1650 Summit Lake Dr. Suite 102, Tallahassee, FL 32317 or by e-mail beneficiary.complaints@acentra.com.
Music: Motivational Upbeat Corporate by RinkevichMusic
https://soundcloud.com/rinkevichmusic
Video Link: https://bit.ly/3NNqGTs
Welcome to Aging Health Matters, a podcast from Acentra Health, a Beneficiary and Family Centered Care Quality Improvement Organization. We plan to cover healthcare topics for the Medicare population. Information in today's show may help you or someone you know in their healthcare journey. Thanks for joining us. Now let's get started.
Hello everyone. We are your hosts today, Melinda, our clinical review nurse, and me, Carla, an operations manager. Acentra Health is a Beneficiary and Family Centered Care Quality Improvement Organization for 29 states. And we help people with Medicare who have concerns about their health care. We can help you appeal if you're leaving the hospital too soon, or if a skilled care like physical therapy is ending too early. We also offer Immediate Advocacy services to help communicate your quality of care concerns regarding medical care or services you or your loved one are currently receiving or have received in the past. For more information, including regional phone numbers to contact us and additional resources, visit our website at acentraqio.com.
Today we'll talk about when and why you might want to file a complaint, share a real-life example, and show you just how easy the process can be. Filing a complaint could lead to a medical record review, a step that helps providers and facilities learn how to improve the quality of care at no cost to the beneficiary. Melinda, let's define what a quality of care complaint actually is.
A quality of care complaint can simply be when someone feels that the medical care they received wasn't good enough or didn't meet the expected standards. Complaints usually involve clinical safety or appropriateness, not something that's like administrative or a service issue, like a wait time of being too long, communication issue that they were being rude to you or they didn't speak very nicely, or billing concerns.
The complaint service is available to Medicare beneficiaries, whether it's traditional Medicare or managed care insurance plans at no cost to the beneficiary, and a complaint can be filed by a beneficiary, a representative for them, whether it's a family member or friend.
So if you know anyone who is unhappy with their care, or you yourself being a Medicare beneficiary, this is a process that is available to you to be able to contact us, whether you use Immediate Advocacy or file a complaint, which as Carla mentioned, would lead to a medical record review regarding the care that you received.
A medical record review has to be for something that is documented in the medical record. Some examples of that would be medication errors. Maybe you got the wrong dosage, or you were to get it twice a day, and you only received it once a day. It could be for a delayed treatment or a misdiagnosis or even a failure to diagnose.
Poor communication regarding a surgery or a procedure that you're to have done. You don't feel that the physician gave you the appropriate treatment options or explains the risks and the benefits of the procedure or surgery fully. A lack of providing you with discharge instructions or follow-up care.
Things that cannot be reviewed because it would not be documented in a medical record. Say you're in a hospital or a skilled nursing facility, and you feel that it wasn't clean. They didn't empty the trash. They didn't pick up your tray in a timely manner. Those are things that would not be documented in a medical record. Unprofessional staff behavior or communications. Felt they were not respectful. That again would not be documented in a medical record, so that could not be reviewed. Billing and coding issues or payment disputes. Those would have to be taken up with the provider and any areas that the QIO, which is Acentra Health, that we are unable to do a review on because it wouldn't be documented in the medical record.
We would provide you with a referral contact, to be able to file a complaint with them for assistance to see if they can provide resolution. And some of those agencies would be like the state Department of Health who does certification for and licensure for a nursing facility and many hospitals. We might direct you to Medicare, your Advantage plan, or back to Medicare directly. It could be if you have fraudulent complaints. Those would be taken up with the Office of Inspector General.
An example of what could be a reviewable concern. Let's just say you were in the hospital, you were being treated for pneumonia, and then you were admitted to a skilled nursing facility because you had weakness and overall physical decline. You were considered a fall risk because of this weakness and that you had to use a wheelchair to be out of bed. While you were in the nursing facility, you were in a wheelchair, and you fell out, and you hit your head and needed further treatment. Your husband believed that the staff should have provided better safety and care for you. And when he voiced his concerns to them, they were uninterested, really didn't seem to care. He placed a call to us here at Acentra Health to discuss the complaint issue and requested to file a complaint and a medical record review. Situations like this are why this process is here for Medicare beneficiaries.
Thank you, Melinda. And now let's discuss how to file a complaint. Filing a complaint is simple, and Acentra Health can help you in every step of the way. Some of the options is that you can actually call Acentra Health, and one of our staff members will talk with you about the concerns and help you start a formal complaint. The other option is that you can actually go online and complete the quality of care complaint form available on our website at www.acentraqio.com under the Information for people who have Medicare and their families and select how to file a quality of care
complaint. You can fill out the form available to you in both English and Spanish.
You can submit the form by mail at Acentra Health. Our address is 1650 Summit Lake Dr. Suite 102, Tallahassee, FL 32317 or by e-mail beneficiary.complaints@acentra.com. Please note that e-mail may not be a fully secure way to send in your information, so just know it's not a very secure or safe way to send in your complaint form.
Once you have signed your form, and we have received it, the review process begins when you receive a call from one of our nurse reviewers to review your form and gather any additional necessary details to request your medical records. You can also download a quality of care review process guide to understand what happens next.
Getting help from one of our representatives means that you don't have to go through this process alone, and you can choose someone like a family member or a friend to help you file a complaint on your behalf. You can even file a complaint on behalf of a family member who has passed away. Just fill out an appoint a representative form, also known as Form 1696.
When you want to contact Medicare directly, if you have a general question about Medicare coverage, enrollment, or billing, you can always contact Medicare, and that's 1-800-633-4227. Remember, you have the right of quality care. If someone doesn't feel right about the care you you're receiving or your loved one has received, reach out to us at Acentra Health.
We're here to help you understand your options and make your voice be heard. For links to all of the forms and guides we mentioned today, check the show notes. If you would like more information about our services, please feel free to sign up for our newsletter as well as subscribe to our YouTube channel. Our Helpline phone numbers as well as a link to our website to sign up for our newsletter will be available in the show notes. Thank you for listening, and please stay tuned for the next episode of Aging Health Matters.
For more information about our beneficiary complaint process, you can also watch our YouTube channel which has a video which explains the entire process. Go to YouTube and put Acentra B F C C in the search bar. Once you have found our channel, the video is titled Do You Have Medicare? Learn How to File a Quality of Care Complaint. Information can be found on our website at acentraqio.com/bene or B E N E, including all forms needed to start the process. Our Helpline staff is available to assist if you have any questions. Remember these services are without costs and are available as part of your rights under Medicare.