Mediation in the Medicare Beneficiary Complaint Response Program
Program Overview

A New Option for Resolving Complaints

The proven benefits of mediation are now being used in the nation’s Medicare program, the health insurer for 42 million Americans. Since 2003, the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, has offered mediation as an optional method to resolve quality of care complaints that Medicare patients or their representatives file involving a practitioner or health care provider.

Background

For many years, Medicare beneficiaries have contacted Quality Improvement Organizations (QIOs), federally funded government contractors located in each state, when dissatisfied with the quality of health care provided by their practitioner or health care provider.

In 1998, CMS sponsored a successful one-year pilot test of mediation to resolve Medicare beneficiary complaints. The pilot revealed that mediation can lead to high satisfaction among beneficiaries as well as improve relationships between them and their health care providers and practitioners. The pilot also showed that mediation may reduce allegations of malpractice brought to court trials.

Mediation

Mediation is a consensual and collaborative process in which the parties have agreed to discuss their problem in good faith and to authorize a third party, the professional mediator, to help them reach a resolution. In contrast to arbitration, the parties themselves decide on an outcome they both agree on.

Mediation is a voluntary process, and either party can withdraw at any time. If either party withdraws, the case reverts to the traditional medical record review process. The mediation process is strictly confidential, no records are kept and nothing said in the hearing can be used in any legal proceedings. If the parties reach an agreement, it is shared with the QIO for follow-up and to ensure that the terms of the agreement are carried out.