Mediation in the Medicare Beneficiary Complaint Response Program

A New Option for Resolving Beneficiary Complaints

The proven benefits of mediation can now be applied to the Medicare program, the health insurer for 42 million beneficiaries across the country. The Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, now offers mediation as an optional method to resolve quality of care complaints that Medicare patients or their representatives file involving a practitioner or healthcare 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 result in high satisfaction among beneficiaries as well as improve relationships between them and their health care providers and practitioners. The pilot also indicated 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 mediate in good faith and to authorize a third party, the professional mediator, to facilitate their efforts to reach a resolution. In contrast to arbitration, the parties themselves decide on the outcome and create a mutually agreed upon resolution.

Mediation is a voluntary process and either party can withdraw at any time, in which event the case would revert to the traditional medical record review process. The mediation process is strictly confidential, no records are kept and anything stated in the hearing cannot be used in any legal proceedings. If the parties reach an agreement it will be shared with the QIO to follow up and ensure that the terms of the agreement are implemented.