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 People with Medicare

 File a Quality of Care Complaint


Please Read: Important Announcement About Medicare Reviews After July 31, 2014

If a Medicare beneficiary has a concern or is not satisfied with the quality of care received, they may call MetaStar at 1-800-362-2320 to discuss their concerns. One of our trained staff will listen to the complaints and help decide how the complaints may best be handled. Options may include the Medicare quality of care review performed by MetaStar or referral of the complaints to another agency.

As a Quality Improvement Organization, we are responsible for reviewing written quality of care complaints lodged by Medicare beneficiaries, regardless of whether they’re a member of Original Medicare or are enrolled in a Medicare Health plan.  These reviews can involve determinations of whether care was reasonable and medically necessary, met professionally recognized standards of health care, or was provided in the appropriate setting.  Please note that federal laws control the way we investigate and respond to your complaint. The law limits the amount of information we are allowed to share with you. Our findings are not allowable in court, and do not directly affect coverage, payment, or billing.

Examples of Medicare quality of care complaints include:

  • Receiving the wrong medication
  • Receiving unnecessary surgery/diagnostic testing
  • Receiving an overdose of medication
  • Experiencing a delay in service
  • Receiving inadequate care or treatment by any Medicare hospital or doctor
  • Experiencing a change in condition that was not treated
  • Receiving a misdiagnosis
  • Receiving inadequate discharge instructions

Complaints about the quality of care received may be reviewed in the following settings:

  • Hospitals and hospital emergency departments
  • Ambulatory surgery centers
  • Rehabilitation facilities
  • Skilled nursing facilities
  • Home health agencies
  • Hospice providers
  • Physician offices

Quality of Care Complaint Review Process

Medicare requires that quality of care complaints be submitted to MetaStar in writing.  You may download the Medicare quality of care complaint form External Link - New Window to document your complaint.  Please mail the completed form to:

MetaStar
2909 Landmark Place
Madison, WI  53713

A nurse review coordinator will contact you when your complaint is received and will serve as your contact person throughout the review process.

An independent physician (one who does not have a relationship with your health care provider or the place where you received care) will review your medical record and determine whether the care you received was similar to what would have been given to you by most health care providers. This is called “meeting professionally recognized standards.”

The physician reviewer looks at all aspects of care surrounding your complaint, and makes an initial finding that is shared with your physician or health care facility that your complaint is related to. Your physician/health care facility has the opportunity to comment. MetaStar works directly with you, your physician and your health care facility to resolve the problem and make sure that you and other Medicare beneficiaries receive quality health care. Our decision will be based on the information written in your medical record. We cannot do other kinds of investigation, such as interviews or site visits. The entire process takes anywhere from three to four months.

Call 1-800-MEDICARE if:

  • You have complaints about care provided outside of Wisconsin
  • You have general questions about Medicare coverage
  • You need clarification on how to enroll in Medicare
  • You wish to discuss billing issues
  • You want to learn more about Medicare benefits and services

You can also visit www.medicare.gov External Link - New Window for general information on Medicare.


  
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