Quality of Care Review Process

Quality of care reviews consist of only what is written in your medical record. If the care you received met minimum standards according to your medical record, CCME will contact you by letter, and the review will end. However, if the review raises questions, we may need more information or medical records to help make a decision. If the case appears to be a good candidate for alternative dispute resolution, we may refer you and your health care provider to these services instead of, or in addition to, the medical record review. Participation in these services is voluntary. The goal of the review process is to identify complaints from poor medical practices that could have or did result in harm to the patient.

Review Process

• A patient submits a written complaint.
• The complaint along with the patient's medical record is sent to a physician reviewer for consideration.
• If the physician reviewer identifies a quality of care concern, the health care provider is given an opportunity to clarify the concerns that were raised in the complaint. The provider may send medical reports with a more detailed explanation about the patient's case.
• The additional reports and the medical record are sent back to the physician reviewer for another determination.
• If the physician reviewer still determines that there are concerns, the health care provider can again attempt to clarify them. The provider may write a letter to explain the care that was given to the patient.
• The medical record and the provider's letter are sent to a physician reviewer that was not involved in the initial reviews.
• This physician reviewer makes the final determination. There is no further review of the complaint after the final determination is made.

How long does a quality of care review take?
A typical review takes about three months. If the reviewer needs more time to answer questions about the care you received, the review can take up to six months.

Your Review Team
A beneficiary review case manager will be assigned as your point of contact throughout the review process. They will work with you and keep you informed of progress in the case. The beneficiary review case manager is also the point of contact for your health care provider.

CCME also selects a doctor from its statewide physician review network whose specialty matches your unique needs. The doctor addresses quality of care concerns with your health care provider and reviews your medical records. They look at all aspects of care surrounding your complaint, and make an initial finding, which is shared with the health care provider that your complaint is related to.

Review Outcome
Rest assured that if your care does not meet standards, CCME will partner with your health care provider to improve future care. The outcome of the complaint review process is educational. CCME does not take punitive action after the complaint review is completed.

• The results of the review are added to a database. The database is monitored for complaints against health care providers.
• A letter is sent to the health care provider with the results of the review. This letter's purpose is to educate both physicians and hospital staff about ways to provide better medical treatment to their patients.
• The results of the review are also mailed to the person who made the complaint to CCME.