Quality of Care Complaints

Quality of Care Complaints

MCS reviews complaints about quality of care by your health plan or its contracted medical providers. Quality of care issues may involve concerns about a provider's knowledge or skill, behavior, attitude, diagnosis and treatment.

Please note, quality of care complaints are peer reviewed. Peer reviewed records are confidential by law - Minn. Stat. ยง145.64. 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 health plans complete peer review file, but we are also prohibited from providing you with information about this file.

This complaint process involves two phases:

1. The investigator gathers information from you and other parties. We will direct your health plan to review your complaint. We notify you that your complaint has been forwarded for a quality assurance review at the health plan.

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
  • have a proper record keeping system
  • ensure that corrective actions resolve the issue.
Our staff will:

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.

The Department can take action against an HMO for its failure to conduct an appropriate internal quality assurance review. Action may include an administrative penalty up to $25,000.

While MCS cannot take action against a licensed provider, you may be able to file a complaint with one of the licensing entities listed below. 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. 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)
• Board of Nursing
  (RNs, LPNs, Midwives, Nurse Practitioners)
• 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.

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 internal review of your concerns. The results of the second phase of our investigation are confidential and cannot be disclosed to you

Updated Friday, January 04, 2019 at 01:31PM