18. Member Complaints, Appeals & Grievances
UCare Quality of Care Review Process
- Quality of Care (QOC) grievances/concerns involve situations where the reporter indicates that the quality of clinical care or quality of service did, or potentially could have, adversely affected a member’s health or well-being.
- Potential clinical QOC situations may be identified and reported internally by any UCare staff person, including Customer Service, Quality Management, Clinical Services, or externally by members or their representatives, delegated entities, regulatory agencies, or providers.
- The QOC grievance/concern is reviewed to ensure that it is appropriate for a QOC review and to determine if the case warrants priority evaluation.
- All cases are reviewed using a confidential Peer Review process.
- A nurse reviewer is responsible for coordinating the QOC review process. The nurse reviewer may collaborate with the Chief Medical Officer or Associate Medical Director to discuss the approach and information needed for the review.
- The nurse reviewer requests medical records and makes observations based on issues presented in the case. The nurse reviewer makes a preliminary determination whether a QOC issue exists.
- For grievances where an organizational provider is the subject of the grievance, the provider may be asked to conduct the investigation and report findings to the nurse reviewer. The provider may be required to submit medical records with the report to confirm findings. If the provider’s response is not satisfactory, UCare may perform an independent review to ensure that appropriate investigation and action is taken.
- If the QOC review indicates a potential serious outcome for other UCare members, the nurse reviewer will immediately consult with the Chief Medical Officer or Associate Medical Director and QM Director to determine if action is needed to protect other UCare members. This may include temporary suspension of member access to the service(s) provided by the provider and transition of current members to the care of another provider, pending the completion of the QOC review.
- After the nurse review is completed, the case is given to a physician to review and documentation of findings and conclusions. The physician reviewer may also request additional information from the provider involved in the grievance or additional records before completing the review.
- The Chief Medical Officer or Associate Medical Director makes the final determination if a QOC issue exists, its severity level, and the action to be taken regarding the case.
- UCare notifies the involved provider/practitioner and appropriate person responsible for supervising the involved provider or staff (e.g. clinic or hospital Medical Director, nursing facility Director of Nursing, etc.) regarding the QOC review outcome if the quality of care issue is substantiated.
If a QOC issue is substantiated, the Chief Medical Officer or Associate Medical Director makes recommendations in the letter about areas of potential process or service improvement. The provider is responsible for ensuring that appropriate measures are implemented to prevent recurrent issues. The provider is then monitored through the threshold monitoring process.