Medicare beneficiaries have the right:

To be admitted to the hospital when medically necessary.
To stay in the hospital until it is medically safe to leave. 
To receive good quality health care.

Just Ask Q & A

 

If you are asked to leave the hospital before you feel well enough, you may obtain a review of your case by Ohio KePRO at no cost to you.

 

YOU MUST:

1. Ask the hospital to put the decision in writing.

2. Immediately call Ohio KePRO's Medicare Beneficiary Hotline at 1-800-589-7337 after the written notice of discharge is given to you.

 

 

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Your right to be admitted to the hospital

 

Medicare beneficiaries have the right to be admitted to the hospital when it is medically necessary. A hospital may not admit you because the services you need can be provided on an outpatient basis. If you feel you need care in a hospital setting, but have been told that Medicare will not pay for your admission, ask for a Pre-admission Denial Letter. This letter is given to you when:

• The hospital does not think that Medicare will pay for your hospital stay.

• In the hospital's opinion, you may require some medical attention, but you do not require acute hospital care.

 

Your rights

You have the right to have Ohio KePRO review your medical case at no cost to you. This will determine whether or not Medicare will pay for your hospital stay. This applies only to beneficiaries with Original Medicare (not a Medicare HMO or other managed care plan). If you are enrolled in a Medicare HMO or another managed care plan, you must appeal admission denials through your plan.

 

Your responsibilities

1. Talk with your doctor about your concerns.

2. Ask the hospital to give to you its decision in writing. This is called a Pre-admission Denial Letter. The letter contains Ohio KePRO's address and telephone number.

3. Call Ohio KePRO's toll-free number at 1-800-589-7337. It is your responsibility to call Ohio KePRO to ask for a review.

 

The Review

When you call Ohio KePRO's Hotline, we will ask you for your name, phone number, Medicare number, the name of the hospital involved, and the date of the Pre-admission Denial Letter. We will forward this information to a nurse reviewer, who will call you back to get more detailed information.

 

When reviewing your case, Ohio KePRO will talk with you, the hospital, and your doctor. Ohio KePRO has the right to approve your admission if we find it is medically necessary for you to be admitted to the hospital.

• If we decide that you need to be admitted to the hospital, you may be admitted to the hospital, and Medicare will pay for medically necessary care.

• If we find that you do not need to be admitted to the hospital, you may still be admitted to the hospital, but Medicare will not pay for your hospital stay.

 

 

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Your right to stay in the hospital

 

How long should I stay in the hospital?
You should stay in the hospital as long as it is medically necessary for you to be there. How long you stay in the hospital should be based upon your medical needs, not your diagnosis.

 

Your rights

You have the right to stay in the hospital as long as it is medically necessary. If you are told that you must leave the hospital before you feel well enough, you have the right to appeal that decision. You may ask Ohio KePRO to review your case at no cost to you. ALL Medicare beneficiaries have the right to appeal, including those in HMOs or other managed care plans.

 

Your responsibilities

1. Talk with your doctor about your concerns.

2. Ask the hospital to give you its decision in writing. You will receive either a Hospital Issued Notice of Noncoverage (HINN) if you are on Original Medicare or a Notice of Discharge Medicare Appeal Rights  (NODMAR)  if you are in an HMO or other managed care plan. This letter explains that the hospital or your managed care plan thinks Medicare will no longer pay for your hospital stay after a certain date. The letter contains Ohio KePRO's address and telephone number.

3. Call Ohio KePRO immediately (by 12:00 noon the next working day) on our toll-free Hotline at 1-800-589-7337. (A family member may make the call for you.) If we are not available to take your call, leave a message on our answering machine, and we will call you back on our next working day.

 

Once you have called Ohio KePRO, you cannot be discharged from the hospital while Ohio KePRO is conducting the review. You will not have to pay for your hospital care until Ohio KePRO makes its decision.

 

The Review

When you call Ohio KePRO's Hotline, we will ask you for your name, phone number, Medicare number, the name of the hospital, and the date the HINN or NODMAR was issued. We will forward this information to a nurse reviewer, who will call you back to get more detailed information.

 

Ohio KePRO will then ask the hospital for a copy of your medical record. The hospital is required to send it to Ohio KePRO within 24 hours. Once we receive a copy of your record, a physician will review it to decide whether or not you require more hospital care.

• If we decide that you need more hospital care, you may stay in the hospital, and Medicare will pay for medically necessary care.

• If we find that you do not need hospital care, Medicare will no longer pay for your hospital stay after Ohio KePRO makes its decision. If you decide to continue to stay in the hospital, you will have to pay for your care starting at 12:00 noon the day after you receive Ohio KePRO's decision.

If you would like a LARGE PRINT COPY of the Hospital Issued Notice of Noncoverage (HINN), call Ohio KePRO at 1-800-589-7337. This will allow you to understand your rights before you enter the hospital.

 

 

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Your right to receive quality medical care

 

If you feel you are receiving or have received poor quality medical care, Ohio KePRO is available to help you.

 

Your rights

You have the right to receive quality medical care. Ohio KePRO is responsible for reviewing complaints about the quality of care received in:

• inpatient hospitals

• hospital outpatient departments

• Medicare HMOs

• hospital emergency rooms

• skilled nursing facilities

• home health agencies

• ambulatory surgery centers

Ohio KePRO performs this service for ALL Medicare beneficiaries, including those in HMOs or other managed care plans.

 

Your responsibilities

1. Call Ohio KePRO on our toll-free Hotline 1-800-589-7337.

2. Be prepared to explain your concerns.

3. Ohio KePRO will send to you a form to complete and sign.

 

 

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We must have your complaint in writing.

 

Immediate Review

If you are currently in a health care facility and you have a quality of care complaint, Ohio KePRO will start our review immediately. We will ask you for some information so that we can get started. We will also send to you a form to complete and sign.

 

Retrospective Review

If you have been discharged from the facility, you (or someone authorized to act for you) can call Ohio KePRO's Hotline at 1-800-589-7337 to request a complaint form. The form asks for the patient's name and Medicare number, the date of admission, the name of the facility where you received care, and a description of your quality concerns. You may also send to Ohio KePRO a letter explaining your complaint.

 

Once Ohio KePRO receives your complaint, we will request a copy of your medical record from the health care facility. A physician will review your case.

 

Your Confidentiality

Ohio KePRO understands that you may not want your doctor to know that you have filed a complaint. Ohio KePRO does not disclose the source of a complaint at the time it conducts a review; however, the identity of the complainant may be inadvertently divulged to the facility and/or physician at the time Ohio KePRO seeks consent to release its findings. If you wish to remain anonymous, Ohio KePRO will not be able to provide you with specific information on its findings; however, Ohio KePRO will still conduct a thorough review and take all the necessary actions available.

 

Our Findings

If Ohio KePRO finds what we think is a problem with the quality of care you received, we will talk to the facility or doctor to recommend ways to handle the same situation in the future. This helps to improve the care provided by the doctor or facility in the future.

 

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Just Ask if you have questions about the quality of your health care

 

Q: What can I do if I have a complaint about the quality of health care given to a Medicare beneficiary?

 

A: Ohio KePRO is the Quality Improvement Organization (QIO) authorized by the Medicare program to review healthcare services provided to Medicare patients in Ohio. Our responsibility includes a review of medical records to determine whether services meet medically acceptable standards of care. We are required by law to thoroughly review all cases with written complaints about the quality of healthcare services. If quality concerns are found, we provide education and feedback to healthcare providers so that they can improve the care they give in the future.

 

If your complaint is about billing or charges for Medicare services, you should call the toll-free number at 1-800-MEDICARE (1-800-633-4227). When you speak to the customer service representative at this number, tell them right away that you have a billing (or charges) issue, and they will help you follow up.

 

If you want Ohio KePRO to review your quality of care concern, you can print out the “Summary of Medicare Beneficiary Complaint” form on this web site. After you complete and sign the form, mail it to Ohio KePRO at the address listed on the form. When we receive it, one of our reviewers will call you to explain our review process and discuss your complaint.

 

You may also call our Medicare Beneficiary Helpline at 1-800-589-7337. You can discuss your complaint with our reviewer on the phone. The reviewer will then send you a complaint form for you to complete, sign, and send to us.

 

Q: Can I submit a quality of care complaint on behalf of someone else?

 

A: You can submit a quality of care complaint for any Medicare beneficiary (for example, a spouse, relative, or friend). However, in order to protect the beneficiary's confidentiality, federal laws may not allow Ohio KePRO to report the detailed results of our review to you unless the beneficiary authorizes it in writing. Even if we cannot report the results to you, we will perform a full review and follow up as appropriate.

 

Q: If I report my concern to Medicare, does the doctor or hospital get in trouble for what has been done?

 

A: The purpose of our review is to help doctors and healthcare providers improve the future care they give to Medicare patients. The purpose is not to punish the doctor or provider. When a concern is found, Ohio KePRO takes steps to find out what caused the concern so that it can be prevented from happening again. We may:

• Educate the doctor or provider on ways they can improve.
• Help the doctor or provider to develop a plan to improve future care.
• Examine more medical records to see if this concern is common.
• Take more steps if you suffered severe harm or the doctor/facility made the same medical mistake before. This could involve sending our concerns to the appropriate agency.

Q: What type of care is right for review and improvement?

 

A: Situations where you believe harm occurred give us the best opening to make improvements and can improve the care of future patients. Some examples are:

• 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 like chest pain; 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.

 

Q: What happens when Ohio KePRO does a medical record review?

 

A: Our review can only cover what is written in your medical record. We must have your doctor or healthcare provider mail a copy to us. Our physician reviewers who examine your record do not have a relationship with your doctor or the facility where your care was provided. The doctor reads your chart to see if your care met professionally recognized standards. If it shows that care met these standards, we contact you by letter and close the case. This takes about 85 days.

 

If this first review raises questions, we may need more information or more medical records to help us make a determination. We may also seek the opinion of another doctor. This may extend the process to 165 days. After the doctor examines the additional information and makes a decision, we contact you by letter.

 

We keep you updated throughout the entire process and encourage you to stay in touch with us as well.

 

Q: What if my concern is not written in the medical record?

 

A: 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 about them that would allow us to make a determination. Issues such as rudeness, cleanliness, or conversations are most likely not documented in the chart. We may refer these types of issues to other appropriate agencies for follow-up.

 

Q: What is written in the medical record?

 

A: Medical records contain information about treatments you received from healthcare professionals such as physicians, nurses and aides, physical therapists, respiratory care therapists, and social service staff. The record should have an entry for each time you were given a medicine and what kind of medicine you received. If your concern is that you didn't get your medicine on time, we can check that and determine if the timing would be considered harmful. If there is nothing written in your chart about the medical treatments you received, this may be an issue we need to examine further.

 

Some examples of what is written in the medical record include your medical history, findings from your physical examination, laboratory and x-ray results, physician orders and physician notes, medications given to you, surgical procedures, social service notes, and vital signs (your blood pressure, heart rate, temperature, etc.).

 

Q: Will I find out what the doctor or hospital did wrong or what their mistakes were?

 

A: We may only be able to tell you if 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 tell you beyond this. The law also gives your doctor the right to limit the information we can share with you. Here are examples of what you may expect to see in our final letter to you.

• If we could not find any evidence to support 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 health care.

We also include a summary of our review findings, if your doctor agrees to the release. If the doctor does not agree to the release, 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 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 health care. We share your concern about the quality of services you received and have initiated appropriate action.

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.

Q: What do you mean when you say my care “meets or does not meet professionally recognized standards”?

 

A: 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 best tailor the clinical guidelines to treat the unique health condition and meet the individual needs of each patient.

 

Professionally recognized standards include the doctor's or provider's use of medical guidelines, their judgment about applying those guidelines to your treatment, and avoiding harm in your treatment. When we review your record, we look at these three areas to be sure that they were at least minimally followed.

 

There is a wide range of treatment that falls within accepted medical standards. 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 have unexpected results.

 

We keep all beneficiary complaints on file. If there is a pattern or trend of similar complaints, we will follow up and take the appropriate action.

 

Q: What happens if my care met accepted medical standards but still could have been better?

 

A: Ohio KePRO looks at every concern to determine whether care could have been improved. If we find that care could have been improved, we work with providers and doctors on any opportunities to make care better. Our final letter to you may include the actions we are taking with the providers to achieve improved care.

 

Q: Does Medicare have other options for me?

 

A: If your concern did not result in potential or actual harm, mediation may be a choice. Mediation brings together the doctor, healthcare provider, and Medicare patient for a face-to-face meeting led by a neutral third party (mediator). Our Ohio KePRO physician reviewer will determine whether mediation is an option. The mediation process is often appropriate for situations where communication between the parties has not been satisfactory.

 

If you want to submit a written complaint to us, please click on the Summary of Beneficiary Complaint form on this website.

 

In order to protect the confidentiality and security of your health information and comply with federal laws about privacy of health information, please do not send this form to us by e-mail. Here are the instructions for completing and mailing the form:

• Print out the form, and write down as much information as you can about your complaint on the form (dates of service, name of facility or physician, and a brief description of your complaint).
• Sign and date the form and mail it to us at:

Ohio KePRO

Rock Run Center, Suite 100

5700 Lombardo Center Drive

Seven Hills, OH 44131

Attn: Review Department

 

If you have further questions, please call us at the Ohio KePRO Helpline at 1-800-589-7337. Our Helpline business hours are 8 am – 4:30 pm Monday through Friday. If you call the Helpline during other times, please leave your name and a phone number where you can be reached, and our Helpline staff will call you back as soon as possible.