Legal & Regulatory

Insurance Quality of Care Q&A

Joan-PorcaroFinal

Question:

I’m an internal medicine physician and I’ve just received a letter from a patient’s insurance company. The patient has complained to them about her care and the insurance company is reviewing that complaint as a Quality of Care Review. What should I do?

Answer:

Patients have the right to file complaints to their insurance company even when they have not addressed the concerns they have with you directly. Such a complaint could result from a perceived error made in your office setting or a communication problem during a recent appointment.

Here are a few important considerations:

  • It is easy to become frustrated at the receipt of such a letter prompting you to make a demanding call to the patient or to hurry off and send an emotional response to the insurance company. Time though will be your ally here. This is when you need to pause, compose yourself and focus on the facts of the situation.
  • Speaking of time, the letter will provide you with a due date. If you feel you will need more time in order to review the case or conduct a review with your office team, call the contact noted on the letter and request an extension.
  • Contact your medical malpractice insurance carrier and provide them with notice about the complaint. Advise them the name of the company or agency that received the complaint. Also, check into your insurance coverage. Find out if you have coverage for an attorney to assist you in composing a response, if needed.
  • Although you are not required to have an attorney write the response or be involved, it is best to discuss the specific case with your insurance company’s claims management or risk management department to strategize the best way to address the complaint.

Avoiding Complaints and Other Solutions

  • Ensure that the staff in your practice are approachable and trained to respond to complaints and concerns.
  • Obtain regular patient feedback. Survey your patients to find out how they perceive you and your team and where they would like to see changes made in their care delivery.
  • Provide patients at their first encounter with the name and phone number of a contact person and a process for problem solving, should situations arise in the future when they are dissatisfied or frustrated with the care received. This can also be advertised on your practices’ website.

Resource:
Medicare.gov (n.d.). Filing a complaint about the quality of your care. Retrieved from https://www.medicare.gov/claims-and-appeals/file-a-complaint/quality-of-care/complaints-about-quality-of-care-.html

Joan M. Porcaro, RN, BSN, MM, CPHRM, is a senior risk management consultant at the Mutual Insurance Company of Arizona.

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