Care Concerns -Frequently Asked Questions
Medical Record Review Frequently Asked Questions
“Most doctors and health providers want to give the very best care to their patients. However, since doctors are human and people run hospitals, neither is perfect. If you believe a Medicare provider may have placed your health at risk, voicing your concern can help make future patient care better.” — Dr. Sharon Hoffarth, Medical Director, Primaris
- What should I do if I am concerned about the quality of my health care?
- How do I know if I should call Medicare?
- If I report my concern to Medicare, does the doctor or hospital get in trouble?
- What happens when Primaris does a medical record review?
- What happens if there is no information to support my concern in my medical record?
- Will I find out what the doctor or hospital did wrong or what their mistakes were?
- What do you mean when you say my care meets or does not meet “professionally recognized standards?”
- What happens if my care met minimum standards but still could have been better?
- Does Medicare have other options for me?
- Where can I go to get help with other health care concerns and complaints?
What should I do if I am troubled about the quality of my health care?
If Medicare paid for the service, call 1-800-Medicare (1-800-633-4227). You will be directed to call us at Primaris. Primaris works to improve health care in Missouri. We talk with you about your concerns and what you can expect if you request a medical record review. We can also help you complete the required paperwork so a full review of your medical record can begin. After our review, we work with providers so that they can provide better care in the future.
How do I know if I should call Medicare?
You should call if you believe that the medical care you received caused you harm—or put you in a position where you could have been harmed—in a way that could have been prevented. These situations give us a chance to work with healthcare providers to make improvements for future patients. Some examples of harmful medical care:
- You received a medication or treatment not ordered for you.
- The doctor operated on the wrong part of your body.
- You were not properly evaluated for a problem, and because of this you did not receive the treatment you needed.
- You developed a bedsore while in the hospital or nursing home because you were not helped to change your position in the bed or chair.
- Your ability to walk decreased after you entered a nursing home due to conditions in the home.
If I report my concern to Medicare, does the doctor or hospital get in trouble?
The purpose of our review is to help doctors and healthcare providers improve the care they give in the future; not to punish the doctor or provider. When a concern is found, Primaris works with the provider to find out what happened so that it will not happen again. We may:- Educate the doctor or provider on ways they can improve care.
- Help the doctor or provider to develop a plan to improve future care.
- Review other patients’ medical records to see if this problem is common.
- Send our concerns to the proper licensing body if you suffered severe harm or the doctor or facility made the same medical error more than once.
What happens when Primaris does a medical record review?
Our review is based only on what is written in your medical record. We ask your doctor or healthcare provider to mail us a copy of your medical record. A Primaris review doctor reads your chart to see if it shows that your care was below professionally recognized standards. The doctor who reviews your record does not have a relationship with your doctor or the facility where your care was provided.
If it shows that care met minimum standards, we contact you by letter and close the case. This takes about 85 days.
If the first review raises questions, we may need more information or more medical records in order to decide if poor care was provided. We may also seek the opinion of another doctor. This may extend the process to 165 days. Once the reviewer makes a decision, we will contact you by letter. Primaris will keep you updated throughout the entire process and encourage you to stay in touch with us.
What happens if there is no information to support my concern in my medical record?
If this happens, we can’t make a decision one way or the other. This does not mean that we believe the things you are concerned about did not happen. It just means that there is nothing in the record that would allow us to make a determination. For example, notes about all your treatments should be in the medical record. The record should have an entry for each time you were given a medicine and what kind of medicine you got. If your concern is that you didn’t get your medicine on time, we can easily check this out and determine if the timing would be considered harmful. Things like rudeness or cleanliness will not be documented in the chart and would not be considered medical problems.
Will I find out what the doctor or hospital did wrong or what their mistakes were?
We may only be able to tell you whether the care you received met professionally recognized standards of health care. If your care did not meet these standards, we work closely with the doctor or facility so that future care will be improved. Federal law limits what we can tell you beyond this. The law also gives your doctor the right to limit the information we can share with you. Below are some examples of what you may expect to see in our final letter to you.
If we could not find any evidence of your concern, your letter may sound like this, "After a thorough review of your medical records and any additional information provided by the facility/doctor, we determined that the services you received met professionally recognized standards of healthcare."
We also include a summary of our review if your doctor agrees to the release. If not, you can expect to see the following statement, "Consent to release detailed information was not granted."
If we find concerns and will be working with the providers to help them improve the future care, your letter may sound like this, "After a thorough review of your medical records and any additional information provided by the facility/doctor, we determined that the services you received did not meet professionally recognized standards of healthcare. We share your concern about the quality of services you received and have initiated appropriate action as warranted by our review findings."
We also include a summary of our findings and information on how we will work with the doctor or facility to improve future care if your doctor agrees to the release. If not, you can expect to see the following statement, "Consent to release detailed information was not granted."
What do you mean when you say my care meets or does not meet "professionally recognized standards?"
You may have heard the phrase, “Do no harm.” This phrase is part of an oath people take when they become physicians. Doctors want to provide the best care possible, but ultimately don’t want to harm the patient with their treatment. To do this, they rely heavily on their own judgment to treat the unique health condition and individual needs of each patient. Professionally recognized standards assess the doctor’s or provider’s use of guidelines, their judgment about how these guidelines best apply to treating you specifically and the avoidance of harm in their final treatment. When we review your record, we look at these three areas to be sure that they were at least minimally followed. Often, patients expect that they receive the very best possible care. The best possible care far exceeds the review we initially do of your record. Care that results in harm could mean that these minimum standards were not met. However, not all care that results in harm is substandard. For example, if there are known complications or risks of your condition or procedure, even care that meets standards could result in harm.
What happens if my care met minimum standards but still could have been better?
We look at every concern to determine if care could have been improved. If we identify opportunities to improve care, we work with doctors and providers to achieve the best care possible. Our final letter to you will include as much information as we can provide about the actions we are taking with the doctor or provider to improve care in the future.
Does Medicare have other options for me?
If your concern did not result in harm or risk of harm, you may have other options. Misunderstandings and poor communication are often the cause of healthcare concerns for people with Medicare. Mediation may be an option in instances of misunderstandings or poor communication. Mediation brings you together with the doctor, hospital, or other healthcare provider for a face-to-face or meeting by phone, led by a neutral third party (mediator). If mediation is a good choice for your case, Primaris will discuss this option with you.Facilitated resolution may be another option. Primaris provides a professional who will talk with you and your healthcare provider in separate telephone calls. The professional will share your concern with your healthcare provider and work with them to improve the care they give. If facilitated resolution is a good choice for your case, Primaris will discuss this option with you. Both you and your provider must agree to participation in mediation or facilitated resolution.
Where can I go to get help with other health care concerns?
The agency that can help you depends on the type of concern you have. Some concerns can be addressed by more than one agency.
- If you think you were released from the hospital or nursing home too soon, or your home health services were stopped before you were ready, contact:
Primaris
200 N. Keene Street
Columbia, MO 65201
1-800-735-6776
- If you have a concern about a physician such as unprofessional conduct, incompetent practice, or licensing questions, you may also contact:
Missouri State Board of Registration for the Healing Arts
3605 Missouri Blvd
Jefferson City, MO 65102
573-751-0098
- If you have a concern about the quality of services not covered by Medicare (services in a nursing home, assisted living facility, or adult day care program) or you have a concern about a hospice agency, contact:
Missouri Department of Health & Senior Services
P.O. Box 570
Jefferson City, MO 65102
573-751-6400
- If you have concerns about nursing home care, you may also contact:
Missouri Department of Health and Senior Services
PO Box 570
Jefferson City, MO 65102-0570
(573) 526-0727 or (800) 309-3282
LTCOmbudsman@dhss.mo.gov
- If you have a concern about Medicare fraud, contact:
1-800-MEDICARE
- If you have a concern about billing, such as questions about charges and what Medicare does or does not cover, contact:
1-800-MEDICARE
or
CLAIM
1-800-390-3330