To protect Medicare beneficiaries and the Medicare Trust Fund, the Centers for Medicare & Medicaid Services (CMS) established Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIOs). BFCC-QIOs help beneficiaries exercise their right to high-quality health care by providing a range of services. Among these services is Immediate Advocacy (IA), an informal process used to quickly address concerns and resolve issues. Examples of concerns that may be addressed through IA include: lack of communication by healthcare staff, not receiving a piece of medical equipment, and problems getting a prescription filled or refilled. The IA process is voluntary for both the Medicare beneficiary and the provider or practitioner. When a beneficiary or representative agrees to participate in IA, the BFCC-QIO contacts the provider and/or practitioner by phone and may facilitate a conversation between both parties. IA is often completed within a few days, making it a timely option for beneficiaries and families.

Immediate Advocacy has expanded in recent years to support more Medicare beneficiaries

Initially introduced as a pilot program, IA services have expanded greatly. Early indicators suggested that IA could be considered as an alternative to addressing concerns through a formal complaint process resulting in a medical record review. With a much quicker turn-around time, and a more “high touch” approach, beneficiaries reported positive experiences with the IA pilot. As part of the five-year BFCC-QIO 12thStatement of Work, CMS expanded the type of concerns addressed through IA and supported the BFCC-QIOs in offering IA as a primary approach to support Medicare beneficiaries.

In 2019, approximately 350 beneficiaries per month were supported through IA services. IA volumes increased considerably in 2020, nearly doubling, following the declaration of the COVID-19 pandemic in March of that year. With the onset of the COVID-19 pandemic, BFCC-QIOs became a source of support and information and further expanded IA services to beneficiaries and families facing new pandemic-related challenges during uncertain times. As of 2022, IA services are offered to an average of 1,220 Medicare beneficiaries per month.

Nearly all providers and/or practitioners engage in the IA process and the majority of beneficiaries report being satisfied with IA services

While the increasing number of IA services delivered is one metric of success, additional data also suggest that IA may be a constructive approach to addressing beneficiary concerns. Between 2019 and 2021, 93 percent of providers and/or practitioners contacted about participating in IA agreed to engage in the process. From the beneficiary and family perspective, nearly 80 percent of individuals who participated in IA reported positive experiences with the service. This metric reflects satisfaction with the BFCC-QIO’s communication, support provided during the process, and beneficiary centeredness.

Another data element collected at the end of the IA process is the beneficiary’s intent to proceed with a formal complaint about the quality of care. From 2019-2021, only 3 percent of beneficiaries indicated that they planned to proceed with a written complaint.

Beneficiaries are more satisfied with IA services when they understand the steps in the process and the role of the BFCC-QIO

Though a majority of beneficiaries were satisfied with IA services, for a small share, IA didn’t meet their needs. CMS saw this as a natural opportunity for quality improvement, and set out to understand more, and identify ways to ensure IA services were beneficiary and family-centered. Data analysis and in-depth interviews with beneficiaries revealed that some beneficiaries had expectations of BFCC-QIO actions or outcomes that were not aligned with the IA process. These included wanting BFCC-QIO staff to conduct in-person facility audits, wanting to know that their concern resulted in a physician being barred from practice, or wanting the inclusion of evidence such as testimony of nurses or family members. Beneficiaries with more positive perceptions of IA services tended to understand the role and limitations of the IA process; some acknowledged that the BFCC-QIO representative had done all that they could, even if they had hoped for a different outcome. In interviews, some beneficiaries noted that the BFCC-QIO had been thorough, but that the scope of the BFCC-QIO’s work was narrow. To help BFCC-QIOs clearly convey the approach and scope of IA services, a plain-language 2-page resource about the IA process was developed and made available on CMS’ beneficiary protection websites.

IA services have grown and evolved since their introduction as a pilot program. Engagement rates and beneficiary feedback suggests that overall, IA provides a convenient alternative for beneficiaries and families to resolve concerns related to their Medicare health care.

The preparation of this publication was performed under Contract No. 75FCMC19D0068 75CMC19F0001, funded by the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services and/or CMS nor does mention of organizations imply endorsement by the U.S. government. The authors assume full responsibility for the accuracy and completeness of the ideas presented.

Stephanie Fry is the Deputy Project Director with the BFCC NCORC.

Laura Gray is the Lead Communications Coordinator with the BFCC NCORC.

Sandra Zelaya is a Communications Specialist with the BFCC NCORC.

The authors declare no conflicts of interest.

Address for correspondence: Wendy Gary, Avar Consulting, Inc. 1395 Piccard Drive, Suite 200 Rockville, MD 20850. (wgary@avarconsulting.com).

Publication Number: ACD-2022-NCORC-0222

This material was prepared by The Bizzell Group (Bizzell), the Data Validation and Administrative (DVA) contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. 12SOW/Bizzell/DVA-1139-07/18/2023