If you want to file a complaint with Medicare, you are not alone. According to the Centers for Medicare and Medicaid Services (CMMS), the agency reviews over 100,000 complaints each year. Complaints cover the quality of care, hospital discharges, home health services, nursing homes, and Medicare Advantage programs, among other things.
The Process of Filing a Complaint
How do you go about lodging your own complaint, or grievance as it is called in the Medicare system? Typically, the process starts with a phone call. However, thanks to some recent changes, the correct phone number to use is not always obvious.
The changes came out of a reasonable concern. Every state has a quality improvement organization (QIO) that had in the past worked on all aspects of quality improvement within the medical system. State QIOs advised healthcare providers on ways to improve metrics like readmissions to the hospital or reduction of infections while also handling the complaints and appeals coming in from health care consumers. Concern about conflicts of interest prompted the split of these functions.
Appeals and complaints are now handled by one of two regional contractors known as Beneficiary and Family-Centered Care Quality Improvement Organizations (you guessed it; they are known as the BFCCQIOs). The companies Livanta and KePro are now the central starting points for filing complaints.
Unfortunately, responsibility is not cleanly divided geographically, so you may not know which contractor handles complaints for your state. You should be given that information through your health care provider upon discharge, but that important information may get lost amid the flurry of paperwork.
As long as it remains valid, the quickest way to find the number for your state is through this link: http://www.nextstepincare.org/Links_and_Resources/.... You can also use the Medicare Helpful Contacts page located at http://www.medicare.gov/contacts/organization-search-criteria.aspx. Select QIO-BFCC (fully spelled out on the link) from the dropdown menu, select your state, and click on the “Find Contacts for this Organization” button. The Medicare site should be the most updated in case of further changes.
If you are comfortable lodging a complaint completely online, you can do so through a separate link on the Medicare website at https://www.medicare.gov/MedicareComplaintForm/home.aspx.
Still confused or need further help? Your State Health Insurance Assistance Program (SHIP) can help you with personalized advice and assistance before you file your complaint. From the Medicare Helpful Contacts page, follow the same procedure as you did to find the proper complaint telephone number, except select SHIP for the organization instead of BFCCQIO. That will give you the contact number to call for your state. If you are confused about the overall complaint process, that may be the best place to start.
Note that there is a difference between a complaint and an appeal. Complaints refer more to how well you were treated by health care professionals, poor equipment used in your health care, or the inability to reach the proper numbers or contacts regarding your Medicare program. An appeal has more to do with disagreements about who pays for services you have received or if you are denied a service that you think that you are entitled to — it has more direct impact on your care.
Appeals start at the same point of contact but go through a different process. If you are not sure how your issue should be classified, that is another reason to start with your state’s SHIP organization.
Regardless of how you file your complaint, ask what sort of feedback you can expect on your complaint, or how you can follow up to ensure the problem is not repeated. There may not be a good answer depending on the nature of your complaint, but you at least have the right to ask the question and expect a response. We hope that your complaint will prevent others from dealing with the same problem — or prevent you from dealing with it a second time.