Filing a Medicare Complaint

Filing a Medicare Complaint

If you believe you have not been treated fairly as a Medicare beneficiary, or if you have not received the benefits you believe you are entitled to, you may file a complaint with the Department of Medicare and Medicaid Services.

To complain about a specific doctor, nurse or other care provider

The best way to complain about a medical care provider is to contact your state medical board directly. This is the appropriate route for complaints about unprofessional or unethical care, incompetent practice, practicing without a license, etc.

To complain about a hospital or clinic

If you want to file a complaint about a hospital, clinic or other facility, contact your state health department. This is the appropriate avenue to take for facilities that are unsafe, have poor access for the handicapped, have air conditioning or heating issues that impact care, have poor food, poor housekeeping or unsanitary conditions.

To complain about quality of care

To complain about the quality of care you received at the hands of a Medicare provider, contact your Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO).

Examples of quality of care complaints include:

  • Drug errors
  • Unnecessary treatments
  • Unnecessary surgery
  • Premature discharges from hospitals
  • Not getting adequate treatment when your condition changes.
  • Poor or incomplete discharge instructions

To complain about your prescription drug plan

If you have a problem with your prescription drug plan and you want the Department of Medicare and Medicaid Services to address it, you mist file the complaint within 60 days of the event or events leading to your complaint.

To do so, contact the plan directly, either in writing or over the phone. Generally, you must be notified of the action or decision regarding your complaint within 30 days of the day your plan receives your complaint.

If your complaint arises because the plan has not made a fast coverage determination and you have not received the drug, the plan must respond with a decision within 24 hours of the time it receives your complaint.

Other plan complaints

For more general plan complaints about such things as customer service, access to specialists, problems with the processing of an appeal, or complaints about information you receive or don’t receive from your plan, you should consult the contact information on your plan membership card.

Complaints about durable medical equipment

To file a complaint about durable medical equipment (DME), contact your supplier first. Your supplier must acknowledge your complaint within 5 calendar days, and send you the result of their investigation within 14 calendar days, per Medicare rules.

If this is not sufficient, call 1-800-Medicare and request your complaint be forwarded to the Medicare Competitive Acquisition Ombudsman (CAO)

Complaints about kidney care

If you are receiving treatment for end-stage renal disease (ESRD) and you have a complaint about your facility, you can contact your ESRD network and file a complaint with them. You may do this if you cannot resolve your complaint at the facility level or if you wish to remain anonymous. This route may be appropriate for complaints about your dialysis or kidney transplant center.

You may file a complaint, for example, if your dialysis shift conflicts with your job and you cannot get your center to change your shift so you can work.

You may also contact your state survey agency if you believe you cannot resolve the situation with the clinic, or if you wish to remain anonymous.

You can find a directory of ESRD Network Organizations here.

Need Assistance?

You can contact your State Health Insurance Assistance Program (SHIP). Assistance is free.

You can contact us as well.

Mike Braun

mikebraun@franklinbenefitsgroup.com

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