Medicare receives over 100,000 complaints annually. You’re not alone if you’re dissatisfied with any aspect of the federal healthcare program. You might be wondering how to express your concerns.
Frequently Asked Questions
What is a grievance Medicare?
A Medicare grievance is a patient’s dissatisfaction with any aspect of a health care provider’s service or even the health care plan itself.
It can be for reasons such as an inability to schedule an appointment with an approved Medicare provider or feeling like you were treated poorly by a doctor, nurse, or other medical staff member.
How do I file a CMS complaint?
The complaint must be written or verbally communicated to CMS within 60 days of the offending incident. So this would likely be a placed phone call, email, or mailed letter to CMS.
Who do you call for Medicare problems?
You can call Medicare directly if you have a Medicare-related problem related to Part A or B.
Appeal versus a Complaint
Appeals are actions that you may take if you disagree with a coverage or payment decision made by your Medicare plan or its administrators.
You file an appeal when you have a problem with your plan, usually if coverage for a service or prescription is denied. This is a separate process to help you find possible solutions.
A complaint isn’t about the coverage itself. Complaints involve the methods and practices by which your Medicare plan or health provider is giving you care.
Your issue is the care you’re getting (or not getting). Complaints center around how you’ve been treated, doctor recommendations, prescriptions, or equipment issues.
Medicare Complaint Categories
- Doctors
- Hospitals or providers
- Your health or drug plan
- The quality of your care
- Your dialysis or kidney transplant care
- Durable medical equipment (DME)
Complaints about a doctor, hospital, or provider often overlap with complaints about the quality of care. For example, you may feel that you were discharged from the hospital too soon or were denied treatment after your condition changed.
In rarer cases, you may feel you were given improper medical advice relating to unnecessary or inappropriate surgery. Common complaints include drug errors, incomplete discharge instructions, and the like.
Medicare Complaint Guidelines
Familiarize yourself with your health plan’s specific rules regarding complaints. If you don’t have a copy of these rules handy, contact your plan and ask them about complaint guidelines.
If you’ve filed your complaint according to your plan’s rules and feel your concerns haven’t been satisfactorily addressed, you can call Medicare directly to speak with a representative.
In addition to consulting with the rep about your complaint, you should ask them to forward it to the Medicare Ombudsman’s office. This office exists to field complaints and inquiries and resolve them to the beneficiary’s satisfaction.
How to File Your Medicare Complaint
Be sure you have basic information on hand when filing your complaint. You’ll need personal information such as your name and address, as well as your Medicare card and health plan card.
You can use Medicare’s Blue Button initiative to download your pertinent information to a file on your local computer.
In addition to the 1-800 number, there’s another way to contact Medicare regarding an appeal or a complaint.
The federal government has contracted with two sizeable regional complaint handlers. You may contact these handlers based on the state where the service you complained about was performed.
- A company called Livanta handles complaints from nine northeastern and eight Western states, as well as complaints from Puerto Rico and the Virgin Islands.
- A company called KePro handles all the rest of the states and Washington, DC.
While contact information for these companies is problematic on Medicare’s official website, The United Hospital Fund has published a complete list of contact phone numbers by state. You can also begin filing a complaint online through the Medicare complaint form.
Filing a Medicare complaint about a provider
The conditions of a doctor’s office or treatment center matter. If you live in an assisted living community, water damage, asbestos, or the lack of a clear fire safety plan will probably make you feel unsafe.
Safety hazards don’t just include the building—staff members also create them. Improper care, like abuse concerns, must be reported.
Your State Survey Agency, which is usually part of your state’s Department of Health Services, handles complaints about unsafe environments and improper care. A complaint can be filed about an assisted living center, hospice, home health agency, or doctor’s office.
If you encounter unsafe or unpleasant conditions at a hospital, you must direct your complaint to your state’s Department of Health Services. You can complain about a hospital’s food, temperature, or cleanliness.
Finally, you may need to file a complaint about your doctor. If they behaved unprofessionally, seemed incompetent, or you aren’t sure about their licensing, go to the state medical board.
Here’s a quick breakdown of what we’ve covered to help you identify the next person to talk to!
| What is the complaint? | Who to contact |
|---|---|
| Improper care & unsafe conditions | State Survey Agency |
| Hospital conditions | State’s department of health services |
| Doctor conduct | State medical board |
As always, if you have a problem with your healthcare plan or questions about coverage, you can contact your agent or My Senior Health Plan.
Filing a complaint about your healthcare or drug plan
Sometimes, your Medicare plan isn’t quite working for you. Remember, a complaint differs from an appeal focusing on your plan’s coverage.
A complaint is for issues with your plan, excluding coverage issues. Your first stop for assistance on coverage should be reaching out to your agent or My Senior Health Plan at 877.255.6273.
You can file a complaint if you have issues with
- Customer service,
- The availability of specialists,
- Communications about your plan,
- An appeals process, or
- The prescription you were given.
For these issues, you can communicate directly with Medicare in writing or over the phone.
If your complaint relates to a specific event, you must file it within 60 days of the event.
Your plan will notify you of any decision or response within 30 days of filing. But if your complaint relates to your plan’s ability to make quick coverage decisions and you are waiting on prescription medication, you’ll receive a decision within 24 hours of filing.
Filing a complaint about your quality of care
Issues with the quality of your care are challenging. Health issues are scary enough. The added layer of being uncertain whether you can trust the care you’re getting—or worse, knowing you are getting inadequate or harmful treatment—takes the experience from bad to worse.
Your quality of care includes a wide variety of concerns. Let’s explore some of the issues you may experience:
- Prescription issues. You may have received the wrong medication or been given medications that interact poorly.
- Surgical issues. You may have received unnecessary surgery.
- Treatment issues. You may have been given unnecessary or no treatment following new developments in your condition.
- Hospital discharge issues. You may have been discharged from the hospital too soon or without instructions for post-admission care.
For these issues, contact your Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO).
Use this online tool to find your BFCC-QIO.
Filing a complaint about kidney care
If you are having issues specifically with your kidney care, thanks to End-Stage Renal Disease (ESRD) Networks, you have more options. ESRD Networks work alongside the State Survey Agencies to handle complaints related to kidney care.
Direct your complaint to your facility or your ESRD Network for concerns about your dialysis or other ESRD care. They must investigate your concerns and ensure you understand your rights. Importantly, no one can take action against you for filing. These complaints range from needing to reschedule your dialysis around your work schedule to being treated disrespectfully.
Your State Survey Agency will also deal with complaints about dialysis and transplant centers. These are the folks to reach out to if you are concerned about abuse, incorrect prescriptions, or unsafe conditions.
Use this tool to find your ESRD Network.
Filing a complaint about medical equipment
Finally, you might want to file a complaint about medical equipment. In this case, contact your supplier.
You can also call Medicare at 1.800.MEDICARE or TTY users should call 1.877.486.2048.
If your medical equipment came through a competitive bidding area, ask your Medicare customer service representative to send you to the Competitive Acquisition Ombudsman.
After filing, you should expect to hear from your supplier confirming they received your complaint within five days. They’ll then send you a written response with the result of your complaint within 14 days.