Alternative Dispute Resolution
Medicare beneficiary complaint cases, received by CCME, that do not exhibit a significant clinical quality of care concern are potential candidates for Alternative Dispute Resolution (ADR). A physician will review all complaints to determine if the case is suitable for ADR. ADR is offered only to qualifying cases and on a limited basis. If the case is appropriate, confidential ADR services may be offered to the Medicare beneficiary and the provider or practitioner instead of, or in addition to, the medical record review. ADR is voluntary and it is free. The beneficiary always has the option to return to the traditional medical record review process if he or she does not believe that resolution has been achieved after ADR has been attempted.
Below are some examples that may help clarify the types of issues that are suitable for ADR:
| Traditional case review |
Alternative Dispute Resolution |
| Medication questions such as dosage or frequency of antibiotic or analgesic. |
Communication issues such as actual or perceived rudeness by provider or staff. |
| Discharge from a facility without adequate discharge plans formulated or implemented by provider. |
The beneficiary is unaware of scheduled surgery delay (or delay in office appointment) due to emergencies. |
| Interpretation of diagnostic test and ordered interventions. |
Poor understanding of policy, procedures, or processes. |
There are three ADR options:
- Mediation – brings a Medicare beneficiary together with a provider (such as a hospital or nursing home) or a practitioner (such as a physician) to talk about the beneficiary’s concerns. To proceed, both parties must agree to participate. The goal is to reach a conclusion that both parties can agree to. Mediation may take place over the phone or face-to-face. These discussions are led by an impartial person trained in mediation.
- Facilitated resolution – does not bring the Medicare beneficiary and health care provider together. There is no direct contact. CCME designates an unbiased facilitator who will speak to the beneficiary and to the provider in separate telephone discussions or by mail. The goal is to provide an opportunity for the Medicare beneficiary to voice their concerns and for the provider to make changes if needed.
- External resolution – occurs when, during the course of mediation or facilitated resolution, the provider or the beneficiary contacts the other party to discuss what might be done to resolve the complaint. External resolution addresses the issues without CCME’s involvement.
ADR benefits Medicare beneficiaries by:
- Offering methods of efficiently and effectively resolving beneficiary complaints as alternatives to the traditional medical record review process.
- Increasing beneficiary satisfaction in both the process and the outcome when addressing complaints in the Medicare program.
- Providing additional ways for providers to learn about the needs and concerns of Medicare beneficiaries in order to implement improvements in health care.
If you have questions about beneficiary complaints or ADR, contact Rita Scott, at rscott@scqio.sdps.org .
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