Quality of Care Complaints
The MCS investigates complaints about quality of care by your health plan or its contracted providers. Quality of care issues may involve concerns about a provider's knowledge or skill, behavior, attitude, diagnosis and treatment.
This complaint process
involves two phases:
1. The
investigator gathers information from you and other parties. We
will review medical records when available to identify areas of concern.
We will direct your health plan to review your complaint and all
identified issues. We notify you that your complaint has been
forwarded for a quality assurance review.
2. Once the
health plan has completed its review, an on-site visit is scheduled. Our
department must ensure that your plan follows its own rules on how to
deliver quality healthcare. Your plan must:
- evaluate and identify problem issues
- include all relevant factors in the evaluation
- create a proper record keeping system
- prove that corrective actions resolve the issue.
1. Interview the quality assurance staff and, as needed, the medical director
2. Review the health plan's internal files to determine if all identified issues have been reviewed and properly recorded.
3. Evaluate the plan during a thorough on-site visit.
Licensed health professionals such as physicians, nurses and psychologists are regulated
by separate licensing boards. Complaints about specific health
professionals can be filed with their respective licensing board.
For further information or to file a complaint, contact the appropriate
licensing board directly. Phone numbers can be found in the state
government blue pages of your telephone directory or by calling the
State of Minnesota general information at (651) 296-6013. Some
frequently called licensing boards are:
• Board of Psychology 612-617-2230 • Board of Chiropractic 612-617-2222 • Board of Dentistry 612-617-2250 • Board of Medical Practice
(Physicians, Physician Assistants, Physical Therapists)612-617-2130 • Board of Nursing
(RNs, LPNs, Midwives, Nurse Practitioners)612-617-2270 • Board of Social Work 612-617-2100 • Emergency Medical Services Regulatory Board
Some health occupations such as speech pathologists, hearing aide dealers, chemical dependency counselors, and unlicensed mental health practitioners, are regulated by the Health Occupation Program (HOP) at the Department of Health. That program can investigate complaints about these practitioners.For further information contact HOP at (651) 201-3731.
Peer Involvement: Depending on the nature of your complaint, your HMO may ask specialty providers to assist in the evaluation process. Not all peer review involves a committee. In some cases, the medical director and another licensed provider may review your complaint and medical records. Highly complicated cases may require a team of reviewers.
Confidentiality: Peer review records are confidential by law - Minn. Stat. §145.64. This means that neither you nor your representative can see the results of the HMO peer review process. The Minnesota Department of Health has the authority to review the HMO's complete peer review file, but we are also prohibited from providing you with information about this file.
Penalties: The Department can take action against an HMO for its failure to conduct an appropriate quality assurance review. Action may include an administrative penalty up to $25,000.
In summary, if you file a complaint related to the quality of health care services delivered to you by an HMO provider, we have a process in place to make sure that your HMO has conducted a thorough review of your concerns. The results of the second phase of our investigation are confidential and cannot be disclosed to you. Upon your request at the conclusion of either phase of our investigation, we will forward a copy of your complaint file to the respective licensing board for its review and possible investigation of the individual licensed provider.
To view the PDF files, you will need
Adobe Acrobat Reader (free download from Adobe's website).
For more information, or to file a complaint, contact the MCS at 651-201-5100 or 1 800-657-3916.
