decisionhealth Newsletters, Answer Books - 2009 Issue 3 (March)
Medicare Contractor Role in Fraud Enforcement / Contractor Benefit Integrity Units / Investigation of Complaints / Disposition of Complaints
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Article Overview
This premium article explains Medicare contractor responsibilities in handling complaints, including how complaints are received, reviewed against referral criteria, acknowledged, and closed. It is aimed at contractors and compliance-oriented readers who need a clear understanding of the complaint workflow, coordination between benefit integrity and medical review functions, and communication expectations with complainants. The material also notes circumstances in which matters may be referred within the contractor or elevated for CMS consideration.
Why This Topic Matters
Understanding the complaint-handling process helps contractors and compliance staff follow Medicare fraud-enforcement procedures consistently and communicate appropriately with complainants. It also clarifies how complaints move between contractor units and when cases may be escalated to CMS.
Article Sections
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Telephone and in-person complaint handling
This section covers how contractor representatives receive complaints and how complaints are initially handled and reviewed. It focuses on the general workflow for evaluating whether a complaint proceeds further within the contractor.
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Written acknowledgement of complaints
This section discusses the timing and content expectations for acknowledging complaints in writing. It also addresses how contractors communicate the status of an investigation to the complainant and how referrals to other contractor components are explained.
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Disposition of complaints
This section addresses notification after a case is completed and the closing steps for complaint handling. It also notes that especially significant matters may be referred for higher-level consideration.
What You Will Learn
- How Medicare contractors handle complaints received by telephone or in person
- What the article says about reviewing complaints against referral criteria
- How contractors are expected to acknowledge complaints in writing
- How complainants are informed when a case is completed
- When matters may be referred within the contractor or to CMS
Who Should Read This
- Medicare contractors
- Compliance staff
- Benefit integrity personnel
- Medical review staff
- Fraud and abuse program administrators
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