Medicare Patients Have Right to Force Government to Make Quality of Care Investigations and to Learn Results

Under a lawsuit known as Public Citizen, Inc. v. Department of Health and Human Services, 332 F.3d 654 (D.C. Cir. 2003), Medicare patients have a right to complain about quality of care issues, force an investigation, and find out the results of the investigation.

Background: Under the Peer Review Improvement Act of 1982, the federal Medicare agency contracts with private organizations of doctors to review quality of care provided to Medicare beneficiaries. These entities are called Quality Improvement Organizations (QIOs) (formerly PROs: Peer Review Organizations). The statute was amended in 1986 to require QIOs to investigate all written complaints "about the quality of services ... not meeting professionally recognized standards of health care," when the complaint is made by a Medicare beneficiary or someone acting on the beneficiary's behalf. 42 U.S.C.  1320c-3(a)(14). The statute requires the QIO to inform the patient "of the organization's final disposition of the complaint." HHS interpreted other confidentiality provisions of the Medicare act to allow QIOs to refuse to divulge the substantive results of their investigations unless the investigated health care provider consented. Public Citizen sued to require HHS and its QIO organizations to reveal the actual results of their investigations. Public Citizen won the case.

Complaints concerning quality of care on behalf of Medicare patients in this area can be sent to:

District of Columbia:
Delmarva Foundation for Medical Care
www.delmarvafoundation.org
202-293-9650
1620 L Street, NW, Suite 1275
Washington, DC 20036

Maryland:
Delmarva Foundation for Medical Care
www.delmarvafoundation.org
410-822-0697 / 410-684-3362
7240 Parkway Drive, Suite 400
Hanover, MD 21076

Virginia:
Virginia Health Quality Center
www.vhqc.org
804-289-5320
4510 Cox Rd., Suite 400
Glen Allen, VA 23060