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Useful Resources
Minnesota Consumer Awareness Education and Resource Guide for 1998
CHAPTER V: Reporting Mechanism
Referral Process Chart
The referral process for suspected fraud and abuse cases is outlined on the MEDICARE F.Y.I. Reporting/Referral Process structural chart (See attachment 5-A ). The referral process begins with the consumer complaint, which would then be referred to the next level in the referral process if appropriate. As this structure indicates, there are several arenas from which referrals of suspected fraud and abuse cases may originate. The arena involving peer educators is the educational forums being held in communities around the region. Other sources of possible fraud and abuse referrals may be the existing Health Insurance Counseling Program (HICP), the Senior Linkage Lineā , or from other individuals, groups, or agencies throughout our region.
Referral Form - Handling Complaints
In addition to presenting materials at the education sessions, peer educators may receive inquiries from the audience about particular incidents they have experienced. The peer educators will have a general background knowledge of the federal and state healthcare programs but are not trained to handle individual complaints. When a beneficiary presents a complaint at an education forum, the peer educator will assist the beneficiary with the completion of the referral form following the education session. It will be explained that a Health Insurance Counselor will review their concerns and contact the beneficiary directly to perform any necessary follow-up to the complaint. Emphasize that although the referral form is being completed, this does not indicate any wrong doing by the medical provider. Indicate that the issue will be reviewed and if further investigation is needed, the appropriate agencies will be contacted. Any inquiry received by the peer educators shall be referred to the MEDICARE F.Y.I. Project Coordinator. Any questions or concerns relating to the referral process may be directed to the Project Coordinator at the local Area Agency on Aging, and may be reached through the Senior Linkage Lineā at 1-800-333-2433.
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CONSUMER COMPLAINT
- MEDICARE F.Y.I. Forums
- Health Insurance Counseling Program
- Senior Linkage® Specialists
- Other Feedback to Complaint Source
PROJECT COORDINATOR / HICP DIRECTOR
- Compile data
- Consumer reassurance / feedback
- Complaint screening
- Additional information documentation
- Complaint review with CMS contractor
- Establish confidential file
- Submit documentation to CMS contractor
- Internal tracking of referrals from all HICP
- Feedback to
- Project Coordinator
- /HICP Director
CMS CONTRACTOR
Review Complaints Internal Referral
- CMS
- Contractor Staff External Referral
Referral Form
DATE______________________
LOCATION________________
MEDICARE F.Y.I.
PEER EDUCATOR REFERRAL FORM
CLIENT NAME_____________________________
PHONE_________________________
STREET ADDRESS_____________________________
CITY_____________________ STATE_____
COUNTY__________________ ZIP_______
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DESCRIPTION OF COMPLAINT:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
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To the best of my knowledge, the above information is
true and accurate, and is provided in a good faith effort to resolve a problem associated
with my Medicare/Medicaid bill. I consent to the disclosure of such information solely for
the purposes of investigating the above complaint. I understand the above complaint will
be referred to trained volunteers, acting in good faith, providing information and
assistance in resolving problems associated with Medicare and Medicaid services and the
accompanying bills. I understand that a Health Insurance Counselor will contact me for
further inquiry, and if warranted, the matter may be referred to appropriate regulatory
and enforcement agencies for further investigation. At all times, however, the information
provided will remain confidential.
Client Signature____________________________
Date_____________
Volunteer Signature_________________________
Date_____________
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