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Centers for Medicare and Medicaid Services

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Measuring the Medicare Beneficiary Experience with the Complaints and Appeals Processes During the 11^th SOW

December 11, 2017

Measuring the Medicare Beneficiary Experience with the Complaints and Appeals Processes During the 11^th SOW

Background:

Data collection regarding beneficiary/representative experience with complaint and appeal processes is being conducted to ensure that these processes are conducted in a beneficiary and family-centered fashion. In this context, beneficiary and family-centered processes can be described as placing the interests, needs, and well-being of the Medicare beneficiary at the forefront of the process, thus ensuring that they are treated in a helpful, respectful, and courteous manner while maximizing the effectiveness and efficiency of the processes.

To adequately support the goals of providing information for the QIO evaluation as well as on-going QIO process improvement during the 11^th SOW, it will be essential to adjust data collection approaches to respond to the changing environment and ensure that we continue to actively and authentically engage beneficiaries and their representatives.

As described in the paperwork reduction act submission CMS 10393 Supporting Statement Part A, the revised data collection instruments rely on a combination of non-duplicative qualitative and quantitative strategies with non-overlapping samples including a voluntary opt-in Web survey for anyone who chooses to provide feedback with no prompt or follow-up from CMS.

Justification of Revisions to Current Survey:

CMS would like to redesign the data collection protocol used to assess the Medicare beneficiary (and representative) experience interacting with the QIOs for the purpose of filing a quality of care complaint or termination of service/discharge appeal. The revisions are intended to maximize utility of data, ensure data are valid and reliable, and minimize burden on Medicare beneficiaries, their families, and representatives. Ultimately, CMS intends to use innovative approaches to gather data to support: (1) evaluation of QIO processes; and (2) on-going QIO process improvement activities.

Survey Crosswalk

The concepts from the existing data collection have been revised to ask about specific experiences while interacting with the Quality Improvement Organizations (QIOs) instead of satisfaction in order to provide more rigorous data to support QIO evaluation and on-going quality improvement. The table below lists the topics covered as well as the specific items addressing each topic in the existing data collection instrument as well as the proposed revised data collection.

Topic	Existing Data Collection	Revised Data Collection – Experience Survey	Revised Data Collection – Direct Follow-up	Revised Data Collection – General Feedback Web Survey	Notes
Sample Verification	Q1 (Our records show that on {DATE} you filed {a complaint/an appeal} about your or another person’s Medicare benefits. Is that right?)	ES-1 (Our records show that on {DATE} you filed {an appeal/a complaint about care or services {you/beneficiary name} received under the Medicare program/ a complaint} about {your/beneficiary name’s Medicare benefits/the quality of care you/beneficiary name received under the Medicare program}. Is that right?	DF-1 (Our records show that on {DATE} you spoke with a representative from {QIO Name}, your QIO. Is that right?)		Language revised to be more specific about the action the beneficiary/representative took.
	Q2 (Have you received the results or findings in response to your {appeal/complaint}?)	ES-11, 12 (Has the complaint process been completed? Have you received your {appeal/complaint} determination? (Appeal: If needed: have you been told about the outcome or result of your appeal? (Medical Records Review: If needed: have you received a letter with the outcome or result of your complaint?)			Selected questions for different case types (non-overlapping questions). Language revised with fill text to reference related event/materials.
Satisfaction with result	Q3 (How satisfied are you with the results or findings in response to your {appeal/complaint}?				Dropped in transition from satisfaction to measures of experience with the process.
Mode of Contact with QIO	Q5 (Did you speak to a QIO representative about your {appeal/complaint}?)	ES-2, 3, 4, 13 (Did you call {QIO Name} to file your {appeal/ complaint}? When you called {QIO Name} to file your {appeal/ complaint}, did you reach a QIO representative or did you leave a message? When you were filing your {appeal/ complaint}, did you ever speak to a QIO representative? How were you notified about the result of your {appeal/complaint}?)		GF-1 (When you were filing your {appeal/complaint}, did you speak to a QIO representative?)	Additional specificity added to understand mode of contact at case intake and at resolution.
Responsiveness	Q6 (How satisfied were you that the QIO representative was as helpful as you thought he or she should be?)	ES-10 (Did the QIO keep you informed about the status of your complaint throughout the process?)			Revised to experience reporting on specific element (informed of case status) of “helpfulness”
	Q10 (How satisfied were you that the QIO representative showed respect for what you said?)	ES-17 (Thinking about your overall experience with {QIO Name} regarding {your {DATE} appeal/your complaint on {DATE}/the complaint you filed on {DATE}, did the QIO representative treat you with courtesy and respect?)	DF-3 (When you spoke with a QIO representative on {DATE}, did the representative treat you with courtesy and respect?)		Revised with specific case references.
		ES-18 (Again, thinking about your overall experience with {QIO Name} regarding your recent {appeal/ complaint}, did the QIO representative involve you and your family as much as you wanted in the {appeal/complaint} process?)		GF-6 (Did the QIO representative involve you and your family as much as you wanted in the process?)	New question to capture patient and family centeredness.
	Q11 (The QIO representative was as responsive to your appeal as you thought he or she should be.)				Dropped in favor of new more specific experience item.
	Q12 (The QIO representative understood the situation related to your appeal.)				Dropped in favor of new more specific experience item.
Communication	Q7 (How satisfied were you that the QIO representative explained things in a way you could understand?)	ES-6, 14, 15 (When you were filing your {appeal/complaint}, did the QIO representative explain the steps in the {appeal/complaint} process? Did the QIO representative explain the results of your appeal? When the QIO representative was explaining the results of your appeal, was the explanation clear?)		GF-3, 4, 5 (How were you notified about the result of your appeal? Did the QIO representative explain the results of your appeal? When the QIO representative was explaining the results of your appeal, was the explanation clear?)	Revised to experience reporting on specific elements of process understanding.
	Q8 (How satisfied were you that the QIO representative spent enough time with you?)	ES-7, 16 (When you were filing your {appeal/complaint}, did the QIO representative spend enough time with you? When explaining the results of your appeal, did the QIO representative spend enough time with you?)			Revised to experience reporting on specific elements of process communication.
	Q9 (How satisfied were you that the QIO representative listened carefully you?)	ES-5 (When you were filing your {appeal/complaint}, did the QIO representative listen carefully to you?)	DF-2 (When you spoke with a QIO representative on {DATE} di the representative listen carefully to you?)	GF-2 (When you were filing your {appeal/complaint}, did the QIO representative listen carefully to you?)	Revised to experience reporting on process.
Community Coordination	Q13 (The QIO representative talked with you about programs and services in your community that are available to help you with your health and wellbeing.				Dropped as concept is not applicable across all beneficiary cases.
Receipt of forms/letters	Q14 (Did you get any forms or letters from the Centers of Medicare & Medicaid Services or the QIO about your {complaint/appeal}?)				Eliminated skip controlling question through more tailored instruments.
Clarity of forms/letters	Q15, 16, 17, 18 (How satisfied were you that the forms or letters you got about your {complaint/appeal} explained things in a way you could understand? How satisfied were you that the forms or letters you got about your {complaint/appeal} had all the information you needed? How satisfied were you that the forms or letters you got about your {complaint/appeal} showed respect for your concerns? How satisfied were you that the forms or letters you got about your {complaint/appeal} were consistent with the information you were told in telephone conversations with the QIO?)				Content on clarity replaced with support for completing forms since QIOs are limited in their ability to change forms/letters.
Support completing forms/letters		ES-8, 9 (When you were filing your {appeal/complaint}, did you need help from the QIO to fill out any forms? Did you get the help you needed from the QIO to fill out the forms about your complaint?)			Replaced content on satisfaction with content of forms/letter with more actionable content on receipt of support completing forms.
Process Rating	Q19 (In responding to your {complaint/appeal} {QIO}, the QIO in your state, gathered information about your {complaint/appeal}, explained the {complaint/appeal} steps, and gave you the results or findings of your case. We are referring to this as the “{complaint/appeal} process”. Using any number from 0 to 10 where 0 is the worst {complaint/appeal} process possible and 10 is the best {complaint/appeal} process possible, what number would you use to rate the overall {complaint/appeal} process?)	ES-19 (Using any number from 0 to 10 where 0 is the worst {appeal/complaint} process possible, and 10 is the best {appeal/complaint} process possible, what number would you use to rate the overall {appeal/complaint} process?)	DF-4 (Using any number from 0 to 10 where 0 is the worst, and 10 is the best, what number would you use to rate the help you got from the QIO?)	GF-7 (Using any number from 0 to 10 where 0 is the worst {appeal/complaint} process possible, and 10 is the best {appeal/complaint} process possible, what number would you use to rate the overall {appeal/complaint} process?)	Streamlined wording.
Follow-up to Immediate Advocacy		ES-20 (Have you or are you planning to follow-up on your complaint with other steps?)			New content added to support analysis for relevant sub-sample.
Comments/Feedback	Q20 (Please give us your comments on the process that was used in responding to your {complaint/appeal}. Include any comments you have on what worked well, and suggestions you have on ways to improve the process.)	ES-21, 22 (What did {QIO Name} do well during your recent {appeal/complaint}? What suggestions do you have for {QIO Name} to improve the process that they use in working with Medicare beneficiaries and their families during the {appeal/complaint} process?)	DF-5 (What suggestions do you have for {QIO Name} to improve how they support Medicare beneficiaries and their families?)	GF-8 (What suggestions do you have for {QIO Name} to improve the process that they use in working with Medicare beneficiaries and their families during the {appeal/complaint} process?)	Divided comment/feedback question to specifically request positive and negative input in order to collect richer data.