Beneficiary Complaints

As the Arizona and California Medicare quality improvement organization (QIO), HSAG administers the Medicare Beneficiary Protection Program in these states. This program is a core function of QIOs and is intended to ensure that the quality of services received by Medicare beneficiaries meets professionally recognized standards of care, are medically necessary, and are delivered in the most appropriate setting. HSAG physicians and nurses, licensed in the state where the patient’s health care is provided, examine all written quality-of-care complaints from Arizona and California Medicare beneficiaries or their designated representatives by evaluating the medical records pertaining to the complaint. Where quality concerns are identified, the QIO offers education and feedback to health care facilities and providers to improve the quality of care for Medicare beneficiaries. If HSAG’s assessment results in a finding that deems a danger to the beneficiary, the QIO may refer the complaint to state licensing boards and/or the Office of the Inspector General to determine if a formal hearing is necessary. This entire process is designed to assure the safety of Medicare beneficiaries by allowing them to address any concerns they may have regarding their care. HSAG produces Annual Medical Services Review Reports that are submitted to the Centers for Medicare & Medicaid Services (CMS) and summarize the number and scope of Medicare beneficiary complaints in both Arizona and California.