Filing a Medicare Complaint

All Medicare enrollees are guaranteed certain rights: the right to privacy, the right to be treated fairly, the right to be protected against unethical practices and the right to receive any health care services you need as allowed under the law. If one of these rights is violated, it is your right to file a complaint or grievance.

Complaints vs. appeals

Complaints are different than appeals. Appeals are filed when you want a Medicare claim reevaluated. If you wish to file an appeal, check out our previous article on claim denial and appeals .

Complaints are when you feel that your Medicare rights are not being met. Some of the things that can warrant complaints include:

• You had a problem with how your doctor treated you
• You weren’t happy with the quality of your care
• You believe a hospital or other facility treated you unfairly
• You weren’t satisfied with the quality of your durable medical equipment
• Your plan’s customer service department was unable to answer your questions

The complaint process

To file a complaint with Medicare, use this form. More serious complaints about doctors or pharmacies should be done though the proper channels as explained in the Medicare complaint guidelines. You can also call 1-800-MEDICARE to file a complaint.

The process for filing a complaint can vary based on the type of compliant you wish to file. Medicare.gov has laid out clear rules for the different types of complaints. We recommend using their links and guidelines when filing a complaint to ensure you are doing it correctly.

How long do I have to file a complaint?

When filing a Medicare complaint, sooner is better. Some programs, like the Part D prescription drug plan complaints, have a 60-day time limit to file a complaint. When filing a complaint, make sure you are filing in a timely manner and following the guidelines Medicare provides to make sure your issues are addressed quickly.

The first question the Medicare complaint form will ask you is if your complaint needs to be addressed in the next ten days. This is to expedite urgent issues that need immediate attention, like medical malpractice. Rest assured that all complaints are answered within 30 days, so if it isn’t an emergency, it will still be handled promptly.

How do I file a complaint about my doctor or hospital?

This depends on the type of complaint you wish to file. If you are reporting unsafe conditions or abuse, you should contact your state’s health department or the medical board if reporting a doctor.

If you have a complaint about the quality of care, contact Medicare and they will help you connect with your local Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). It’s their job to review care quality complaints.

How do I file a complaint about durable medical equipment (DME)?

The first step is to contact your DME supplier. The supplier has five days to let you know they have received your complaint and 14 days to report the results of any investigation into the issue. If the supplier doesn’t resolve it to your satisfaction, you may be able to file an appeal or take additional action against the supplier. You should also contact Medicare, using either the online form or by calling 1-800-MEDICARE, and report the issue.

How do I file a complaint about my Medicare Advantage plan?

Medicare Advantage plans (and all non-Original Medicare coverage options) are issued by private insurance companies. Although they are regulated by Medicare, each carrier handles complaints internally within the company. To file a complaint about your Medicare Advantage plan, you will need to contact your provider and follow the rules for their complaint process.

How do I file a complaint about my Part D Prescription Drug Plan?

Part D plans are offered by private insurance companies, so all complaints should be filed with the provider. However, Medicare does offer some guidelines.

Medicare rules state that you have 60 days from the date of the incident you’re complaining about to contact your plan and file a complaint. You can either write to the insurance company or contact them by phone. You should be able to find the appropriate contact information on your insurance card or in your plan brochure.

Once your insurance company receives your complaint, they have 30 days to respond. If the complaint deals with a refusal to make a prompt and favorable decision about a service or prescription drug, they must respond within 24 hours.

If you are unhappy with their response, you have the right to contact Medicare and file an appeal. You can also get in touch with your local BFCC-QIO if the issue relates to quality of care. In all cases, your State Health Insurance Assistance Program (SHIP) is available to help you contact Medicare or file a complaint. Help from your SHIP is always free for Medicare beneficiaries.

Conclusion

In all cases, the complaint process is there to help you. The goal of the complaint process is to eliminate deficiencies in the program and weed out doctors and hospitals providing insufficient care. Your rights are important, and it’s important to find a quality plan that serves your needs.

If you are unsatisfied with your current insurance or are looking to make a switch, PlanEnroll is here to help. Contact one of our licensed insurance agents for a zero-cost coverage consultation.

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