Improvement Projects > Beneficiary and Family Centered Care > Case Review

Ohio KePRO is the Medicare Quality Improvement Organization serving Ohio's 1.8 million Medicare beneficiaries. Ohio KePRO's purpose is to make sure that people on Medicare receive the health care that they are entitled to, and that the care they receive meets nationally recognized quality standards. One of Ohio KePRO's tasks is to review complaints and concerns from people on Medicare who were treated in any healthcare setting.

Review of Quality of Care Complaint Ohio KePRO reviews complaints and concerns from people who on Medicare about medical care. For example, a patient may have:

• been given the wrong medication
• been given inadequate care or treatment by a health care staff worker
• had a premature hospital discharge
• had a change in a condition that was not treated

Information for Review The review is based on information contained in the medical record created during the episode of care.

Reviewers Ohio KePRO has two types of reviewers.

1. Physicians
   • Located throughout Ohio
   • Practicing in a wide range of specialties
   
   
2. Review Coordinators
   • Nurses
   • Health Information Professionals

Review Process The goal of the review process is to identify those complaints of poor medical practices that could have or did result in harm to the patient.

• A patient submits a complaint.
• The complaint along with the patient's medical record is sent to a physician reviewer for a consideration.
• If the physician reviewer identifies a quality concern. The health care provider is given an opportunity to clarify the concerns that were raised in the complaint. The provider may send medical reports with a more detailed explanation about the patient's case.
• The additional reports and the medical record are sent back to the physician reviewer for another determination.
• If the physician reviewer still determines that there are concerns, the health care provider can again attempt to clarify them. The provider may write a letter to explain the care that was given to the patient.
• The medical record and the provider's letter are sent to a physician reviewer that was not involved in the initial reviews.
• This physician reviewer makes the final determination. There is no further review of the complaint after the final determination is made.

Review Outcome The outcome of the complaint review process is educational.

• The results of the review are added to a database. The database is monitored for complaints against healthcare providers.
• A letter is sent to the healthcare provider with the results of the review. This letter's purpose is to educate both physicians and hospital staff about ways that they can provide better medical treatment to their patients.
• The results of the review are also sent in a letter to the person who made the complaint to Ohio KePRO.

Ohio KePRO does not take punitive action after the complaint review is completed.

Other Reviews Ohio KePRO reviews the medical records of hospital patients who are given the Important Message from Medicare, as well as patients receiving services from skilled nursing facilities, home health agencies, comprehensive outpatient rehabilitation facilities, or hospice providers who are given a notice of non-coverage. Read more about discharge appeals.