Complaints and Grievances

CMS has changed the way we (ESRD Networks) receive and investigate patient grievances.  We will handle grievances in one of two ways:  Immediate Advocacy or Quality of Care Review.  The table below provides the definitions and processes of our new grievance types.

Grievance Type Definition Process
Immediate Advocacy A dispute resolution process in which the Network is able to quickly resolve a grievance by making direct contact with the involved provider and/or practitioner(s) The Network and facility will work together to find a resolution that is suitable for both the facility and the patient.

Quality of Care Review

A careful, timely review that the Network conducts in response to a written or oral grievance

Such a grievance may allege one or more of the following.

  • a patient’s rights were violated
  • a Medicare-covered ESRD service did not meet professionally recognized standards of care
  • the failure to meet recognized standards resulted in an adverse clinical outcome.

Two types of Quality Care Reviews:

  1. Patient-Specific Quality of Care   Review –  on behalf of an individual patient
  2. General Quality of Care Review –  on behalf of two or more patients

The Network and the Facility will take these steps:

  1. Facility will receive a request for documentation/medical records from the Network.
  2. Facility should send the requested documentation within 10 business days.
  3. After the Network has reviewed the documentation, it will request more documentation if needed. Once it has analyzed sufficient documentation, the Network will send a letter of the initial findings to the facility.
  4. Facility must provide any comments regarding the letter of findings within 15 business days.
  5. If the grievance is substantiated, the facility’s comments must include its steps to resolve the grievance.
  6. Once the Network has received the comments, it will mail the patient a determination letter.