Mediation to Resolve Beneficiary Complaints

Colorado Medicare beneficiaries are now able to resolve quality of care complaints against health care providers through an optional mediation program. The new program, sponsored by the Centers for Medicare & Medicaid Services (CMS), an agency of the Department of Health and Human Services, brings together a provider or physician and a patient or his/her representative for a face-to-face meeting facilitated by an impartial mediator. Mediation is an alternative to the traditional medical record review process.

Mediation allows a physician or health care provider to engage in a discussion with a patient who has filed a quality of care complaint. It allows both parties a chance to tell their story and resolve their disputes in a neutral and confidential environment.

Mediation is not available if a serious quality of care concern is involved. However, up to 80 percent of quality of care complaint cases are driven by lack of communication or patients' concerns about their interaction with physicians. For these cases, mediation can help resolve complaints quickly and result in higher satisfaction rates for providers and patients alike. More importantly, it can help to prevent the case from getting into the highly adversarial process of litigation.

Currently, each beneficiary complaint goes through a medical record review process that can last anywhere from 85 to 165 days, depending on whether or not a quality of care concern is found. 

Actual mediation may only take a few hours, and when a settlement is reached the patient's dissatisfaction is relieved and the physician is saved from more time-consuming processes such as licensing, investigations, or litigation.

In each case CFMC determines if mediation would provide an appropriate solution. Cases already in litigation, for example, cannot be mediated. The mediation process is voluntary, so both the patient and provider must agree to mediation before the process can be used.

The national mediation program was preceded by a successful six-state pilot project. Evaluations of the pilot suggested that most beneficiaries and providers who participated in mediation were satisfied with both the process and the outcome.