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For People with Medicare
HealthInsight, as the Quality Improvement Organization (QIO), works collaboratively with Medicare, health care providers and practitioners in Nevada and Utah to improve the quality of health care delivered to you or your loved ones. We provide assistance to people with Medicare providing education regarding rights, responsibilities and more.
What are my rights?
Through Medicare you have a number of patient rights designed to safeguard your health and your health care. As a Medicare patient you have the right:
- To receive all the hospital care necessary to diagnose and treat your medical condition. Your care should be based on your medical condition. When you are admitted to the hospital, you receive a copy of the Important Message from Medicare. This explains your rights and includes Medicare's toll-free phone number for you to call if you think you should have received specific care or services you did not receive in the hospital.
- To receive quality medical care. Care provided to you in any Medicare-certified setting can be reviewed for quality. Medicare-certified settings include inpatient hospitals, surgical centers, skilled nursing facilities, home health agencies, comprehensive outpatient rehabilitation facilities, emergency rooms, hospices, hospital outpatient areas, outpatient physical therapy and speech language pathology services, physician offices and more. If you believe you did not receive quality health care, call 1-800 Medicare. Contact HealthInsight at 800-748-6773 to express a concern or file a complaint.
- To be notified in writing by your provider if they determine Medicare will no longer pay for your care. If you think your services are being terminated or you’re being asked to leave the hospital too soon, you have the right to request a written notice and you can call HealthInsight at 1-800- 748-6773 right away to appeal the termination of services.
- To be fully informed about what is covered by Medicare and what is not covered. You should be told when medical services are not covered. If you are expected to pay for services, you should be notified in advance. This allows you to be fully informed about decisions that affect your Medicare coverage. You may be asked to sign an Advanced Beneficiary Notice (ABN).
How do I appeal a Notice of Non-coverage?
Beneficiaries or their representatives may call the QIO Case Review Department upon receipt of a hospital, nursing home, home health, hospice and comprehensive outpatient rehabilitation (CORF) facilities issued Notice of Non-Coverage, for a review of their care. All Medicare patients, including managed care enrollees, are entitled to a review of their medical stability as evidenced by the medical record, with protection against premature discharge, and an assurance that an adequate, safe patient discharge plan has been formulated and that the patient has been properly informed about their discharge rights. The review also identifies liability for payment, and describes further appeal rights.
If you have questions, please call our toll free appeals helpline at 1-800-748-6773.
This line is staffed seven days a week including weekends and holidays. If no one is available when you call or you are calling after hours, please leave a message and we will return your call as soon as possible.
How do I share a concern or complaint?
It is one thing to know your rights and another to exercise them if need be. If you believe you are not receiving quality medical care, please follow these steps.
Step 1 - Discuss your concerns with the facility and/or physician who is providing the treatment. Most facilities have patient relations staff who can assist you in resolving your concerns.
Step 2 - If Step 1 is not possible or does not achieve desired results, assess whether your concern can be reviewed by us. In order for a concern to be considered for QIO review, the subject must be a quality-of-care concern and the setting must be a Medicare certified facility (see below).
Step 3 - If your concern is a subject and setting we can review, continue to Step 4. If your concern is not something the QIO can review, please call 1-800 Medicare (1-800-633-4227) for an appropriate referral to an agency that can assist you.
Step 4 - If we can review your concern(s), please call HealthInsight at 1-800-748-6773 if you have any questions or need to obtain a complaint form.
Subject - The QIO reviews clinical quality of care issues such as:
- early discharge;
- medication - wrong type, wrong dose;
- inappropriate diagnosis or treatment by any health care professional;
- therapy ordered but not received; and
- wound care not provided.
The QIO cannot review issues regarding:
- hospital food
- your hospital room;
- rude behavior of a health care professional;
- delay in answering of nurse call button;
- customer service; or
- other issues that do not directly impact quality of medical care, or are not documented in the medical record.
Setting -The QIO reviews quality of care issues in any Medicare-certified facility such as:
- ambulatory surgery centers
- home health agencies
- hospices
- hospitals
- mental health facilities
- nursing homes
- rehabilitation facilities
- physician offices
- skilled nursing facilities
Click here for an informational brochure "Medicare Beneficiary Protection Program - Quality of Care Concerns". How will my complaint be resolved?
There are two methods for resolving clinical quality of care complaints. The first is through the process of Medical Record Review and the second is through Alternative Dispute Resolution.
- Medical Record Review is one option to resolve a quality of care complaint under Medicare. This is at no cost to you, the patient. When HealthInsight receives a written complaint about the quality of services received by a Medicare beneficiary, we will request a copy of the medical record. A physician will review the medical record and make a final determination about the care received. The review process could take three to six months to complete, during which we will keep you informed of the progress of the review. When the review is complete, we notify you of the final decision.
- Alternative Dispute Resolution is a form of conflict resolution which focuses on the communication between the health care provider and the patient. Click here for more information.
You should know that by law, we may not be able to tell you what happened to the health care provider as a result of your case. But by filing a complaint, you put in motion a process that determines whether or not the care you received "met professionally recognized standards of care." We are here to make sure everyone gets the proper treatment and will use the findings from your complaint to improve care for future patients. Although we can't change what happened to you, we can make sure it doesn't happen to anyone else.
For more detailed information about your rights and protections as a Medicare beneficiary, please download the following PDF or go to www.medicare.gov.
Call our Medicare Beneficiary Hotline 1-800-748-6773 for more information.
How do I contact the QIO?
HealthInsight
6830 West Oquendo Road, Suite 102
Las Vegas, Nevada 89118
Other Resources for People with Medicare
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