Dear Marci,

My mother recently received a misdiagnosis, resulting in unnecessary and painful treatment. We are so upset about her situation but are not sure what to do about it. Is there anything Medicare beneficiaries can do when they receive poor quality of care?

-Vincent (Abbeville, SC)


Dear Vincent,

I am so sorry to hear about your mother’s situation. If you have a concern about the quality of care she received from a Medicare provider, your concern can be directed to the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) for your area. The BFCC-QIOs are made up of practicing doctors and other health care experts. Their role is to monitor and improve the care given to Medicare enrollees. BFCC-QIOs review complaints about the quality of care provided by physicians, hospitals, skilled nursing facilities, home health agencies, and ambulatory surgery centers. 
 
Examples of situations about which you might wish to file a quality-of-care complaint include: 

A medication mistake 
Developing an infection during a stay in a facility
Receiving the wrong care or treatment 
Running into barriers to receiving care 
 
You can file a quality-of-care complaint by calling your QIO or submitting a written complaint. When the BFCC-QIO gets your complaint:
They should call you to ask clarifying questions about your complaint and to get the contact information for your provider.
A physician of matching specialty will review the medical record to determine whether the care provided met the medical standard of care, or whether the standard of care was not met.
You and your doctor will be notified by phone and in writing when the review is over (the review process can take up to a few months).
 
Livanta and KEPRO are currently the two BFCC-QIOs that serve the entire country. To find out which BFCC-QIO serves your state or territory and how to contact them, visit www.qioprogram.org/locate-your-bfcc-qio or call 1-800-MEDICARE. 
 
If you have a Medicare Advantage Plan, you can choose to make complaints about the quality of care you receive through your plan’s grievance process, through the BFCC-QIO, or both.

Your state may have other ways for you to file a complaint about a provider or facility You may be able to file a complaint through the consumer or patient protection sections within your state’s office of the Attorney General. You can also consider filing a complaint through the state licensing boards that oversee providers, for example, the Board of Medicine or the Nursing Board.

I hope your mother is doing better and that this information is helpful to you all.

-Marci

Dear Marci,

I received a favorable decision on an appeal to my Medicare Advantage Plan to cover the cost of a doctor’s office visit. I had already paid for the cost of the visit out of pocket, and my plan notified me that I would receive a reimbursement. It has been months and I have still not received one. What should I do?

-Shruthi (Los Angeles, CA)


Dear Shruthi,

If you are dissatisfied with your Medicare Advantage or Part D prescription drug plan for any reason, you can choose to file a grievance. A grievance is a formal complaint that you file with your plan. It is not an appeal, which is a request for your plan to cover a service or item it has denied. Times when you may wish to file a grievance include:

If your plan has poor customer service
You face administrative problems (such as the plan taking too long to file your appeal or failing to deliver a promised refund)
You believe the plan’s network of providers is inadequate

To file a grievance:
Send a letter to your plan’s Grievance and Appeals department. Check your plan’s website or contact them by phone for the address.
You can also file a grievance with your plan over the phone, but it is best to send your complaints in writing.
Be sure to send your grievance to your plan within 60 days of the event that led to the grievance.
You may also want to send a copy of the grievance to your regional Medicare office and to your representatives in Congress, if you feel they should know about the problem. Go to www.medicare.gov or call 1-800-MEDICARE to find out the address of your regional Medicare office.
Keep a copy of any correspondence for your records.

Your plan must investigate your grievance and get back to you within 30 days. If your request is urgent, your plan must get back to you within 24 hours. If you have not heard back from your plan within this time, you can check the status of your grievance by calling your plan or 1-800-MEDICARE.

Best of luck filing your grievance and getting your reimbursement!

-Marci

Dear Marci,

My sister just went to her doctor for an Annual Wellness Visit and recommended I do the same. I don’t think I’ve had this type of appointment before, though. What is it and what should I expect?

-Douglas (Westminster, CO)


Dear Douglas,

The Annual Wellness Visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on your current health and risk factors. Keep in mind that the AWV is not a head-to-toe physical. Also, this service is similar to but separate from the one-time Welcome to Medicare preventive visit.

During your first Annual Wellness Visit, your PCP will develop your personalized prevention plan. Your PCP may also:

Check your height, weight, blood pressure, and other routine measurements
Give you a health risk assessment
Review your functional ability and level of safety
Learn about your medical and family history
Make a list of your current providers, durable medical equipment (DME) suppliers, and medications
Create a written 5-10 year screening schedule or check-list
Screen for cognitive impairment, including diseases such as Alzheimer’s and other forms of dementia
Screen for depression
Provide health advice and referrals to health education and/or preventive counseling services aimed at reducing identified risk factors and promoting wellness

AWVs after your first visit may be different. At subsequent AWVs, your doctor should:
Check your weight and blood pressure
Update the health risk assessment you completed
Update your medical and family history
Update your list of current medical providers and suppliers
Update your written screening schedule
Screen for cognitive issues
Provide health advice and referrals to health education and/or preventive counseling services

Original Medicare covers the Annual Wellness Visit at 100% of the Medicare-approved amount when you receive the service from a participating provider. This means you pay nothing (no deductible or coinsurance). Medicare Advantage Plans are required to cover AWVs without applying deductibles, copayments, or coinsurance when you see an in-network provider and meet Medicare’s requirements for the service.

Contact your healthcare provider if you want to schedule your Annual Wellness Visit!

-Marci

The first day of spring is Sunday, March 20! With warmer weather and more colorful seasonal foods also comes potential seasonal allergies. As plants release pollen, millions of people with allergies may experience runny nose, watery and itchy eyes, sneezing, and/or coughing (WebMD). If you believe you may have seasonal allergies, you can speak with your primary care doctor, who may refer you to an allergist for tests. In addition to prescription allergy treatments, you can also find over-the-counter medicines that ease the symptoms of allergies caused by spring’s trees, grasses, and weeds.

Does Medicare cover depression screenings? I’ve read about how depression is more common in older adults, and I want to be sure I am not missing signs and symptoms.

-Sara (Chapman, ME)


Dear Sara,

Yes, Medicare Part B covers an annual depression screening. The annual depression screening includes a questionnaire that you complete yourself or with the help of your doctor. This questionnaire is designed to indicate if you are at risk or have symptoms of depression. If your results show that you may be at risk of depression, your provider will perform a thorough assessment and will refer you for follow-up mental health care if appropriate.

Depression screenings should be conducted by your primary care provider (PCP) or another trusted doctor to ensure that you are correctly diagnosed and treated. In most cases, you should receive your depression screening when you have a scheduled doctor’s office visit, often during your annual wellness visit. However, you can also ask your provider to screen you during a separate visit.

You do not need to show signs or symptoms of depression to qualify for screening. However, the screening must take place in a primary care setting, like a doctor’s office. This means Medicare will not cover your screening if it takes place in an emergency room, skilled nursing facility (SNF), or hospital.

If you qualify, Original Medicare covers depression screenings at 100% of the Medicare-approved amount when you receive the service from a participating provider. This means you pay nothing (no deductible or coinsurance). Medicare Advantage Plans are required to cover depression screenings without applying deductibles, copayments, or coinsurance when you see an in-network provider and meet Medicare’s eligibility requirements for the service.

Finally, if you are having thoughts of suicide or are concerned that someone you know may be having those thoughts, in the United States you can call the National Suicide Prevention Lifeline at 800-273-8255 (TALK) or go to SpeakingOfSuicide.com/resources for a list of additional resources. Click here for a list of international resources.

Remember that depression screenings are a healthy and important part of everyone’s preventive care! You can learn more about Medicare’s coverage of behavioral health services here.

-Marci