When a Medicare beneficiary has a complaint not related to the clinical quality of care she or he received, the beneficiary can agree to participate in a process called Immediate Advocacy with her or his healthcare provider to get an answer to their complaint quickly.
Immediate Advocacy is an informal alternative dispute resolution process used to quickly resolve a verbal complaint a Medicare beneficiary or their representative has regarding the quality of Medicare-covered health care received. This process involves the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) directly contacting the beneficiary’s practitioner and/or provider, usually by telephone.
Immediate Advocacy can be a useful process for beneficiary complaints unrelated to clinical quality of health care received by a provider, but can relate to services that accompany their medical care. These are examples of complaints that may be resolved through Immediate Advocacy:
- Complaints about a lack of communication by hospital staff
- Concerns about the failure to receive a motorized scooter, wheelchair, or another piece of equipment
- Difficulty scheduling an appointment for a prescription refill
Immediate Advocacy Success Stories
Concerns About Care at the Hospital Regarding a Patient’s PICC Line
A Medicare beneficiary contacted KEPRO with concerns about his care at the hospital when his peripherally inserted central catheter (PICC) line pulled out. The hospital did not have anyone to address the situation, so he was placed in observation until the PICC line could be replaced. He had been in the hospital all weekend, requested to leave, and was told he could not leave. He did not feel it was necessary for him to be in the hospital and requested that no charges be billed because there was no one available to address his situation.
The KEPRO Intake Specialist contacted the QIO Liaison at the hospital. The QIO Liaison stated that the beneficiary had every right to be upset, as he should not have been kept in the hospital all weekend. She stated that an on-call person should have been notified, but the hospital staff did not call the right people. She also stated the appropriate processes were not followed, and changes were being made to make sure that this does not happen again. She also advised that the hospital would not bill for his stay.
The KEPRO Intake Specialist then contacted the beneficiary, and he was very appreciative of the intervention on his behalf. He shared that the PICC line had been replaced and that he was being discharged that day.
Concerns about Durable Medical Equipment
Livanta successfully completed an Immediate Advocacy for a beneficiary who required the use of a continuous positive airway pressure (C-PAP) machine at night. The patient received a call from the durable medical equipment (DME) supplier indicating the C-PAP machine was to be returned, as they believed she no longer needed the machine. The beneficiary was upset and stated she still needed to use the machine.
A Livanta employee contacted the DME supplier and the physician who ordered the C-PAP machine. The supplier told Livanta that the patient was past her 90-day period for evaluation and continued use of the machine. However, the physician notes, in the patient’s record, indicated that the beneficiary was recently hospitalized, and that prior authorization and evaluation efforts should be continued. Premature retrieval of the equipment would have placed the beneficiary at risk. The Livanta employee continued the Immediate Advocacy process. The DME supplier halted the equipment retrieval efforts until they could obtain the prior authorization documentation. As a result, the beneficiary was able to use the C-PAP machine without interruption.
Contact your BFCC-QIO for more information about Immediate Advocacy.
BFCC-QIO Contact Information by Region or State
Northeast and Caribbean:
Connecticut, Massachusetts, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Puerto Rico, Rhode Island, Virgin Islands, Vermont
Mid-Atlantic and Southeast:
Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia
Mountain, North Central, and South:
Alabama, Arkansas, Colorado, Kentucky, Louisiana, Mississippi, Montana, New Mexico, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, Utah, Wyoming
Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio, Wisconsin
Alaska, Arizona, California, Hawaii, Idaho, Nevada, Oregon, Washington