CMS-R-0282 Medicare Appeals and Quality of Care Grievances

Sample Report
(Appendix 2)

Medicare Appeals and
Quality of Care Grievances
Organization X
April 1, 2006 to March 31, 2007

What kind of
information is
this?

When you ask for it, the government requires Organization X to provide
you with reports that describe what happened to formal complaints that
Organization X received from their Medicare members. There are two
types of formal complaints: Appeals and Grievances.
Medicare members have the right to file an appeal or grievance with
their Medicare Advantage organization. The next few pages contain
information about the appeals and quality of care grievances that
Organization X received between April 1, 2006, and March 31, 2007.
Each organization will have different numbers of appeals and quality of
care grievances, and these numbers can mean different things. For
example, an organization might have a small number of appeals and
quality of care grievances because the organization talks with members
about their concerns and agrees to find solutions. Or an organization
might have a small number of appeals and quality of care grievances
because its members are not aware of their right to file an appeal or
grievance.

How big is
Organization X?

Page 1

Organization X has about 88,000 Medicare members.
(line 3 on the attached report)

Appeals Information beginning on Page 2
Quality of Care Grievance Information on Page 6

OMB Approval No. 0938-0778

Form No. CMS-R-0282

Information on Medicare Appeals
April 1, 2006 to March 31, 2007
What is an
appeal?

An appeal is a formal complaint about Organization X's decision not to
pay for, not to provide, or to stop an item or service that a Medicare
member believes she/he needs.
If a member cannot get an item or service that the member feels she/he
needs, or if the organization has denied payment of a claim for a service
the member has already received, the member can appeal. For example,
a member might appeal Organization X's decision to stop physical
therapy, to deny a visit to a specialist, or to deny payment of a claim.

How many
appeals did
Organization X
receive?

Organization X received 174 appeals from its Medicare members.
About 2 out of every 1,000 Medicare members appealed Organization
X's decision not to pay for or provide, or to stop a service that they
believed they needed.
(lines 2 and 4 on the attached report)

How many
appeals did
Organization X
review?

Organization X reviewed 157 appeals during this time period.

What happened?

From the 174 appeals it received from its members:
Organization X decided to pay for or to provide all services that the
member asked for 41% of the time.

(lines 5 through 8 on the attached report)

Organization X decided not to pay for or to provide the services that the
member asked for 49% of the time.
Medicare members withdrew their request before Organization X issued
a decision 10% of the time.

Page 2

Expedited or “Fast” Appeals Information on Page 3

OMB Approval No. 0938-0778

Form No. CMS-R-0282

Information on Expedited or “Fast” Appeals
April 1, 2006 to March 31, 2007

What is a “fast”
or expedited
appeal?

A Medicare member can request that Organization X review the
member's appeal quickly if the member believes that his or her health
could be seriously harmed by waiting for a decision about a service. This
is called a request for an expedited or “fast” appeal.
Organization X's looks at each request and decides whether a “fast”
appeal is necessary. By law, Organization X must consider an appeal as
quickly as a member's health requires. If Organization X determines
that a “fast” appeal is necessary, it must notify the Medicare member as
quickly as the member's health requires but no later than 72 hours.

How many “fast”
appeals did
Organization X
receive?

Organization X received 20 requests for "fast” appeal from its Medicare
members.

What happened?

When a member requested a “fast” review, Organization X agreed that a
“fast” review was needed 75% of the time.

(lines 14 through 16 on the attached report)

Organization X did not agree to a “fast” review 25% of the time. This
number may include requests by members who the organization may not
have believed were in danger or might suffer serious harm.

Page 3

OMB Approval No. 0938-0778

Independent Review of Appeals on Page 4

Form No. CMS-R-0282

Information on Independent Review
April 1, 2006 to March 31, 2007

What is
Independent
Review of an
appeal?

After a member has sent an appeal to Organization X, if the
organization continues to decide that it should not pay for or provide all
services that the member asked for, Organization X must send all of the
information about the appeal to an independent review entity (IRE) that
contracts with Medicare, not with Organization X.
An independent review provides an opportunity for a new, fresh look at
the appeal outside of the organization. CMS’ IRE goes over all of the
information from Organization X and can consider any new
information.
If the IRE does not agree with Organization X's decision, Organization
X must provide or pay for the services that the Medicare member
requested.
There may be several reasons why the IRE decides to agree with either
the Medicare member or Organization X. For example, the IRE may
disagree with Organization X because the IRE may have had more
information about the appeal.

Page 4

Quality of Care Grievance Information on Page 5

OMB Approval No. 0938-0778

Form No. CMS-R-0282

Information on Independent Review
April 1, 2006 to March 31, 2007

How many
appeals did the
IRE consider?

The IRE considered 86 appeals from Organization X.
(lines 9 through 13 on the attached report)

What happened?

The IRE agreed with the Medicare member's appeal 19% of the
time. This means that in 19% of these cases, Organization X
ended up paying for or providing all services that these members
asked for.
The IRE disagreed with the Medicare member's appeal 70% of
the time. This means that in 70% of these cases, Organization
X ended up not paying for or providing all services that these
members asked for.
Medicare members withdrew their request for independent review
9% of the time.
By June 01, 2007, 2% of appeals were still waiting to be
reviewed by the IRE.
NOTE: These percentages may not add to 100% because
sometimes the IRE dismisses an appeal.

Page 5

Quality of Care Grievance Information on Page 6

OMB Approval No. 0938-0778

Form No. CMS-R-0282

Information on Quality of Care Grievances
April 1, 2006 to March 31, 2007

What is a quality A grievance is a complaint that a Medicare member makes about the way
of care grievance? Organization X provides care (other than complaints about requests for
service or payment). A grievance about the quality of care is one kind
of grievance. For example, a member can file a grievance about the
quality of care when the member believes that the service the member
received was not timely or correct, when the member had problems
getting a service because of long waiting times or long travel distances,
or when the wrong kind of doctor or hospital provided the service.

How many
quality of care
grievances did
Organization X
receive?

Organization X received 20 grievances about the quality of care. About
less than 1 out of every 1,000 Medicare members filed a grievance
about the quality of care they received from Organization X doctors and
hospitals.

Where can I get
more
information?

If you are a member of Organization X, you have the right to file an
appeal or grievance.

(lines 2 and 4 under “Quality of Care Grievance Data” on the attached
report)

You can contact Organization X at (insert phone number) to resolve a
concern you may have or to get more information on how to file an
appeal or grievance. (Be sure to include a phone number for the hearing
impaired and your hours of operation.) You may also refer to your
Evidence of Coverage for a complete explanation of your rights.
You also can contact a group of independent doctors in STATE, called a
Quality Improvement Organization, at (insert QIO’s phone number) for
more information about quality of care grievances or to file a quality of
care grievance.

Page 6

OMB Approval No. 0938-0778

Form No. CMS-R-0282