Complaint procedure draft 11706

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Complaint procedure draft 11706 Powered By Docstoc
					Complaint procedure draft 1/24/06

Policy: Under Oregon Law 2005, chapter 675, section 5 the director shall develop a process of
investigating and reviewing complaints about independent medical exams. This must include
standards for referring complaints to the appropriate health professional regulatory board and an
appeals process for a physician who disagrees with an action taken by the director.

Goal: Receive and investigate complaints about independent medical exams. Determine when to
refer a complaint to the appropriate health professional regulatory board or another workers’
compensation program area. Remove a physician from the list of authorized medical providers
when the health professional regulatory board sanctions a physician.

Note: - Any party may file a complaint

       - Complaints may be filed: anonymously, in-person, letter, fax, telephone, email, on-
       line complaint form submission

       - Complaints may be filed with the division IME Coordinator in-person at 350 Winter St
       NE, Salem, Oregon, by letter mailed to PO Box 14480 Salem, Oregon 97309-0405, by
       fax at 503-947-7794, by telephoning 503-947-7583 in the Salem area, or state-wide
       1-800-425-0288 x7583, by sending an e-mail to wendy.m.stone@state.or.us, or on-line at
       www.wcd.oregon.gov.


Procedure:
Support or IME Coordinator: Receive complaint.

Support:       Log complaint in database.
               Create file – “hard” copy/ system if first complaint regarding physician.
               Enter data into file hard copy/system.
               Forward complaint to IME Coordinator.

IME Coordinator: Determine what category complaint falls within (see Appendix categories).
                     The category may change as the investigation progresses.
             Investigate allegations, including interview any witnesses, if appropriate.
             Advise complainant of action being taken, as appropriate.
             Notify IME facility, if applicable.

               If category 1, send notice/letter to physician advising of complaint received.
               - notice/letter will explain:
                       - no action is being taken, complaint does not describe a possible violation
                       of the specific health regulatory board, or in the absence thereof, the
                       ABIME “Guide of Conduct,” or workers’ compensation rule or statute,
                       - record of complaint will be maintained in file and log,
                       - additional complaints received could result in an investigation, and
                        - if additional complaints are received, physician could be removed from
                 IME list.

                 If category 2, forward to appropriate unit/section/division
                         - If complaint includes collateral issues involving other categories,
                 process accordingly.
                         - If appropriate program to handle complaint is this one, first investigate
                 whether there have been any previous similar complaints about this physician. If
                 not, contact physician to educate on rule/statute. Document discussion with
                 follow-up letter, including the fact that a record of the complaint will be
                 maintained in file and log, additional complaints received could result in an
                 investigation, and if additional complaints are received and validated, physician
                 could be removed from IME list.
                         - Advise complainant that complaint involved issue(s) regulated by other
                 WCD program area(s), and it has been forwarded for appropriate processing or
                 outcome if handled in this unit.

                 If category 3, Use “internal filter” with medically knowledgeable employee.
                         - If agree category 3, notify appropriate health regulatory board and
                         forward complaint.
                         - If complaint includes collateral issues involving other categories,
                         process accordingly.
                         - Follow-up with health regulatory board to determine if action, was or
                         will be taken; or if sanctions have or will be imposed.
                                  - If the health regulatory board takes action resulting in any
                         discipline/reprimand/sanctions, contact the physician to advise that their
                         name will be removed from the IME list until they are once again in
                         “good-standing”, or sanctions have been satisfied or lifted.
                         - Advise physician of appeal rights.
                         - Remove physician name from IME list.
                         - Notify complainant, if appropriate, of outcome.

Support:         Data enter resolution of complaint and date into data system.
                 Send letter(s) to complainant, physician, and any other parties identified notifying
                 of complaint resolution. Retain copy of resolution in hard file.



Appendix

Categories of Complaints:

- Category 1: (least offensive) Complaint describes a minor offense with no apparent or possible
violation of the specific health regulatory board, or in the absence thereof, the ABIME “Guide of
Conduct,” or workers’ compensation rule or statute. Example: My appointment was for 1:00 PM,
but I didn’t see the doctor until 2:30.


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- Category 2: (of more concern that category 1) Complaint describes no apparent or possible
violation of the standards pertaining to independent medical examinations or guidelines
established by the specific health regulatory board, or in the absence thereof, the ABIME “Guide
of Conduct.” However, complaint does describe a behavior, act or practice or demonstrates an
example of noncompliance with or possible violation of workers’ compensation rules/statute that
may warrant referral to a different unit or section within WCD for appropriate processing or
education. Example: The doctor wouldn’t let my observer stay in the exam room with me.

- Category 3: (worst of three categories) Complaint describes a possible violation of the
standards pertaining to independent medical examinations or guidelines established by the
specific health regulatory board, or in the absence thereof, the ABIME “Guide of Conduct.”
Example: Female patient asked by male doctor to remove her top when injury was to the knee.
The doctor insulted and belittled me. The IME report did not reach conclusions based on facts
and sound medical knowledge.




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