From time to time, CMS receives complaints that may be resolved informally without the necessity of formal peer review. CMS authorizes grievance resolution services to assist Members in facilitating resolution of misunderstandings and disputes.
2. Jurisdiction and Scope
Grievances may be referred for resolution services and may include, without limitation:
- Discourteous service;
- Release of medical records;
- Billing or administrative errors;
- Communication issues; and
- Confidentiality concerns.
Grievance resolution services shall not concern a Member’s:
- Association or lack of association with a professional organization;
- Fees, advertising, or competitive acts;
- Participation in group health plans, salaried employment, or any manner of delivering health services whether on a fee-for-service or other basis; or
- Association with a particular class of health care provider or professional organization (including support, practice, supervision, training, delegation).
3. Grievance Resolution Committees (GRCs) Structure and Participation
GRCs shall provide services and are authorized to act or make recommendations
- Authority. The Board authorizes CMS and Component GRCs, individually and collectively, to assist in resolution of grievances in substantial compliance with these Bylaws.
- Composition. GRCs shall consist of at least three Members and are subject to composition, eligibility, and terms of office rules as follows:
Disqualification. GRC Members who are in direct economic competition with the Member who is the subject of a grievance, have been involved in the matter underlying the grievance, have a close relationship with the grievant or affected Member, or otherwise have an interest in the outcome, or any other conflict, shall be disqualified from participating in services for that grievance.
- CMS GRC: according to Chapter VI, §13 of these Bylaws.
- Component GRC: defined by each Component Society.
Grievance resolution services are confidential among the participants. Accordingly, all records, notes, minutes, recommendations, and correspondence shall be kept confidential. Disclosure of information to the participants, CMS Executive Office, Credentials Committee, or a Component Society shall not violate confidentiality.
5. Grievance Resolution Process
- Requests for Grievance Resolution Services and Initial Screening.
- Requests for Services. Grievances must be in writing and describe specific conduct. Grievances may be made by any person.
- Screening and Acceptance. Grievances shall be reviewed by one or more GRC members to ensure jurisdiction.
For any reason, the GRC may decline to provide grievance resolution services or may refer a matter to the formal peer review process described in Chapter VII (a). Matters originating in a hospital may be referred to a hospital representative. Requests pending before other entities may be declined as duplicative.
The GRC will attempt to make determinations within 30 days, but may defer a decision if more time or information is needed.
- Notification. If the GRC declines to provide services, a letter, copied to the affected Member, shall be sent notifying the grievant.
If a grievance is accepted for resolution services, a letter shall notify the grievant and the affected Member. Such letter should explain the process and may contain appropriate releases. Failure of a grievant to promptly return such releases is cause to terminate services. The affected member should be sent a copy of this Chapter VII of the Bylaws.
- Investigation and Resolution.
- Effort to Obtain Facts. The GRC shall make a reasonable effort, within the sole discretion of the GRC, to obtain the facts underlying a grievance.
- Resolution. At any time after reasonable effort to obtain the facts about a grievance, the GRC may:
- Attempt to mediate a resolution between the parties.
- Make recommendations to one or both parties.
- Terminate further services and notify the affected Member and grievant.
- Reports. At least annually, each GRC shall submit a list of committee member names along with the number of grievances submitted to the GRC and the disposition of such grievances.
- Record Retention. Records of grievance resolution services shall be retained by CMS in accordance with the following:
- If grievance services are declined or a grievance is referred to another entity or process at the screening stage, CMS shall retain the file for 90 days.
- If, after investigation, the GRC terminates services, the file shall be retained for 90 days.
- If, after investigation, the GRC makes recommendations or attempts mediation, the file shall be retained for three years.