Medicare supports the health of 44 million Americans. The health and safety standards established by Medicare are meant to protect you. If you experience any form of improper care or treatment, then you need to know how to properly file a complaint. We’ve provided some helpful guidance recommended by Medicare.gov on what actions you need to take.
What is the Difference Between a Compliant (Grievance) and an Appeal?
A complaint is about the quality of care you received or are receiving. For example, you may file a complaint if you have a problem calling the plan provider or if you’re unhappy with how a staff person at the plan has treated you. However, if you have an issue with a plan’s refusal to cover a service, supply, or prescription, you should file an appeal.
What Can I file a Complaint For?
A complaint can be filed for various reasons but most common complaints include:
- Claims of abuse to a person in a nursing home
- A mistake in giving out or prescribing medication
- Poor quality of care in a hospital (including psychiatric and rehabilitation hospitals) nursing home, dialysis facility, ambulatory surgery center, home health agency hospice, intermediate care facility for the mentally impaired
- Unsafe conditions, like water damage or electrical or fire safety concerns
- Laboratory results that were wrong and lead to improper care
How do I file a Complaint?
If you have a complaint, note that each plan has specific rules you’ll need to know and follow when filing a complaint. If, after filing a complaint, your plan doesn’t address the issue, call 1-800-MEDICARE for help. For any Medicare-related complaint, you can call your State Health Insurance Assistance Program (SHIP) for free personalized help.
If you’ve contacted 1-800-MEDICARE about a Medicare-related inquiry or complaint but still require further assistance, ask the 1-800-MEDICARE representative to send your inquiry or complaint to the Medicare Ombudsman’s Office. The Medicare Ombudsman’s Office helps make sure that your inquiry or complaint is resolved.
- Your name, address, and telephone number
- Name of health care provider
- Location of health care provider (including room or floor, if applicable)
- Details of your concern (including the date and time)
- Name(s) of other people involved and/or affected
- Whether you have reported this complaint to anyone else, including the provider. If so, what was the response?
- What you would like to see happen to resolve your complaint
What Can I File an Appeal For?
You can appeal if Medicare or your plan denies one of the following:
- Your request for a health care service, supply, item, or prescription drug that you think you should be able to get
- Your request for payment for a health care service, supply, item, or prescription drug you have already received
- Your request to change the amount you must pay for a health care service, supply, item or prescription drug
How Do I File an Appeal?
If you decide to appeal, ask your doctor, health care provider, or supplier for any information that may help your case. See your plan documentation, or contact your plan for details about your appeal rights.
You can usually find your plan’s contact information on your plan membership card. Or, you can get your plan’s contact information from a Personalized Search (under General Search), or search by plan name.