Funding Focus

Putting Complaints to Work

We are often the last stop on a patient's long, sometimes arduous journey of seeking care. We claim to have a streamlined, top-notch health care system in America, yet patients often report having to repeat something as basic as demographic information several times in one day while seeking care for the same event.

By the time patients present at our stores or on the phone, they are tired, frustrated and often just plain angry. When these emotions present, it is difficult for patients to hear. Gone are the instructions you so carefully gave regarding deductibles and co-pays. Vanished are the words regarding how to access after-hours help. Forgotten are the teachings of equipment maintenance.

The knowledge that "we did everything right" can cause us to easily dismiss rantings from irrational clients. It does not help that human nature gives us fragile egos and makes us fear getting a co-worker in trouble. It is a wonder complaint logs are not covered in dust.

Three of the 21 DMEPOS supplier standards specifically contain the word complaint. They are:

  • Number 13 — A supplier must answer questions and respond to complaints of beneficiaries and maintain documentation of such contacts.
  • Number 19 — A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of the complaints must be maintained at the physical facility.
  • Number 20 — Complaint records must include name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.

In addition to the supplier standard requirements related to beneficiaries, providers must adhere to the CMS Quality Standards released in August 2006. Under the heading "Consumer Services," the standards state: "Within five calendar days of receiving a beneficiary's complaint, the supplier shall notify the beneficiary, using either oral, telephone, e-mail, fax or letter format, that it has received the complaint and that it is investigating. Within 14 calendar days, the supplier shall provide written notification to the beneficiary of the results of its investigation and response. The supplier shall maintain documentation of all complaints that it receives, copies of investigations and responses to beneficiaries."

Those in the HME industry need to look at their complaint log as a protective mechanism, not as an admission of guilt or indicator of poor business practice. Tracking the number of complaints that your company receives each quarter can reveal if it is time for a staff reminder that documentation of complaints protects the company, as opposed to harming it.

For example, not too long ago, a patient called the benefit integrity unit complaining that her HME provider had given her poor quality equipment and had refused requests to replace it. More than six months passed before the HME supplier received an official notice from the Supplier Audit and Compliance Unit (SACU) of the National Supplier Clearinghouse (NSC) that the facility had been found to be in violation of one or more of the 21 DMEPOS supplier standards. The supplier then had 21 calendar days from the date of the letter to provide the SACU with information to verify full compliance. If the provider failed to provide the information, the SACU would then initiate actions to revoke the provider's supplier number.

Of course, at this point the provider had no way of knowing what prompted the letter. Fortunately, when sending in the complaint log and documents, the date and scenario matched up, and clearly showed evidence that the supplier had made numerous trips to the patient's home verifying the equipment was working properly and had actually replaced the equipment on two different occasions.

The 2006 Quality Standards also require that the supplier measure the timeliness of responses to beneficiary questions, problems and concerns. Make sure your complaint log contains a date column for "beneficiary notified of resolution."

Most of all, embrace and articulate to all staff the belief that your complaint log is oftentimes the only insurance to keeping your supplier number.

This article originally appeared in the Respiratory Management March 2008 issue of HME Business.

About the Author

Kelly Riley, CRT, is director of The MED Group's National Respiratory Network and has more than 25 years of experience in the respiratory arena.

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