A Medicare beneficiary can agree to participate in a process called Immediate Advocacy with her or his health care provider to get an answer to a concern quickly.
Immediate Advocacy is an informal alternative dispute resolution process used to quickly resolve a verbal complaint a Medicare beneficiary (or his or her representative) has regarding the quality of Medicare-covered health care received or services that accompany medical care (e.g. medical equipment). This process involves the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) directly contacting the beneficiary’s practitioner and/or provider, usually by telephone. The process is totally voluntary for both the beneficiary and the provider or practitioner.
Examples of complaints that may be resolved through Immediate Advocacy include (but are not limited to):
- Complaints about a lack of communication by hospital staff
- Concerns about the failure to receive a motorized scooter, wheelchair, or another piece of equipment
- Difficulty scheduling an appointment for a prescription refill
Immediate Advocacy Success Stories
Concerns About Care at the Hospital
A Medicare beneficiary contacted KEPRO with concerns about his care at the hospital when his peripherally inserted central catheter (PICC) line pulled out. The hospital did not have anyone to address the situation, so he was placed on observation status until the PICC line could be replaced. He had been in the hospital all weekend, requested to leave, and was told he could not leave. He did not feel it was necessary for him to be in the hospital and requested that no charges be billed because there was no one available to address his situation.
KEPRO contacted the QIO liaison at the hospital who stated that the beneficiary had every right to be upset, as he should not have been kept in the hospital all weekend. She stated that an on-call person should have been notified, but the hospital staff did not call the right people. She also stated the appropriate processes were not followed, and changes were being made to make sure that this does not happen again. She also advised that the hospital would not bill for his stay.
KEPRO contacted the beneficiary, and he was very appreciative of the intervention on his behalf. He shared that the PICC line had been replaced and that he was being discharged that day.
Concerns about Durable Medical Equipment
Livanta completed the Immediate Advocacy process for a beneficiary who required the use of a continuous positive airway pressure (CPAP) machine at night. The patient received a call from the durable medical equipment (DME) supplier indicating the CPAP machine was to be returned, as they believed she no longer needed the machine. The beneficiary was upset and stated she still needed to use the machine.
Livanta contacted the DME supplier and the physician who ordered the CPAP machine. The supplier told Livanta that the patient was past her 90-day period for evaluation and continued use of the machine. However, the physician notes, in the patient’s record, indicated that the beneficiary was recently hospitalized, and that prior authorization and evaluation efforts should be continued. Premature retrieval of the equipment would have placed the beneficiary at risk. The DME supplier halted the equipment retrieval efforts until they could obtain the prior authorization documentation. As a result, the beneficiary was able to use the CPAP machine without interruption.
Contact your BFCC-QIO for more information about Immediate Advocacy.
BFCC-QIO Contact Information by Region or State
Northeast and Caribbean:
Connecticut, Massachusetts, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Puerto Rico, Rhode Island, Virgin Islands, Vermont
Mid-Atlantic and Southeast:
Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia
Mountain, North Central, and South:
Alabama, Arkansas, Colorado, Kentucky, Louisiana, Mississippi, Montana, New Mexico, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, Utah, Wyoming
Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio, Wisconsin
Alaska, Arizona, California, Hawaii, Idaho, Nevada, Oregon, Washington