May 2014 Quality Topic

Complaint Training

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TDI – Definition of Complaints • Complaints are an oral or written expression of dissatisfaction with a

Utilization Review Agent (URA) concerning their process in conducting a utilization review.

• The term "complaint" does not include:

An expression of dissatisfaction constituting an appeal

A simple misunderstanding or misinformation that is resolved promptly by supplying the appropriate information or by clearing up the misunderstanding to the satisfaction of the complaining party.

• All complaints must have prompt follow-up and resolution.

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Types of Complaints

• Complaints can be either verbal (telephonic) or written (email/mail).

Verbal complaints should be addressed and resolved at the time of the call when possible.

All complaints are acknowledged to the complaining party in writing by the receiving party or his/her representative within five (5) calendar days.

The complaints procedure must include a requirement for a written response to the complainant by the agent within 30 calendar days.

• Documentation of both written and verbal complaints along with their resolutions, should be summarized and emailed to your supervisor for tracking.

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Examples of Complaints

• Vendors complaining that they were not paid for services rendered in a timely manner

• Members calling to complain that a staff member was rude • Members calling to complain that they were on hold too long

and/or disconnected during a phone call • Payors complain that billable work was conducted on a termed

patient and they refuse to pay

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How to Handle a Complaint

• Staff receiving a complaint should thoroughly document the date of the complaint, the complaint summary, who is involved and any other information that may assist in the resolution process.

• Staff member should fill out a Complaint Form and turn in to

either their Supervisor or Compliance Officer.

• Supervisors will keep a copy of all complaints received in their office so they are accessible for further review.

• Records of complaints must be maintained for three years from the date the complaints are filed.

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How to Handle a Complaint (cont.)

• Supervisor and/or Compliance officer will research issue and seek proper solution to resolve the complaint within 30 days

(typically we try to resolve that day if possible). • Complaint details and resolution are documented on Complaint Log

to monitor for trends • Complaints are also discussed in CQI meetings to keep quality staff

updated and informed

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Definition of Incidents

• Incidents are a series of events that involves a breach of security or violation of PHI.

• Incident Compliance are when these issues or violations conducted

by the organization are identified, analyzed, and corrected to avoid future mishaps

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Examples of Incidents

• Sending a letter containing PHI to the wrong address and/or fax number • Issuing pre-authorizations on the wrong patient with same name • Attaching documents to wrong case file • Leaving PHI on a member’s voicemail

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How to Handle an Incident • Document the incident by completing a HIPAA incident form and

submitting to your Supervisor or Compliance officer • Supervisor and/or Compliance officer will follow-up incident and make

sure issue is resolved. • Incident is logged and monitored for trends

and discussed in CQI quality meetings

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Final Thoughts

• Remember that…

Complaints are typically issues externally brought to our attention Incidents are usually PHI violations or issues that we discover internally

• When in doubt on deciding if you issue is a complaint, incident, or neither, always go ahead and submit to your Supervisor and/or Compliance Officer.

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Take Your Completion Survey!

Please click on the link below to complete the May Quality Topic completion survey. The answers to the quiz questions can be found in this presentation.

ALL Care Management staff is responsible for submitting their online completion survey by May 30th.

Completion Survey Link:

https://www.surveymonkey.com/s/May2014QualityTopicSurvey

Please contact Karen Owens if you have any questions.

Email: karen.owens@healthsmart.com | Phone: 214.574.2816

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