Things don’t always go according to plan. When unforeseen challenges or mistakes occur with your Medicare, it is helpful to know where to voice your concerns and who can help.
First, it’s helpful to know how to file a grievance with a Medicare Advantage or Part D plan. A grievance is a formal complaint that you file with your Medicare Advantage or Part D prescription drug plan. A grievance is not the same as an appeal, which is a request for your plan to cover a service or item that it has denied. Times when you may wish to file a grievance include if:
Your plan has poor customer service
Your plan takes too long to decide on an appeal
Your plan fails to deliver a promised refund
To file a grievance, send a letter to your plan’s Grievance and Appeals department within 60 days of the event that led to the grievance. Visit your plan’s website or call the plan for the address. You can also file a grievance with your plan over the phone, but we recommend keeping a written record of the name of the person you spoke to, the date and time of the call, and the outcome of the call. Your plan must investigate your grievance and get back to you within 30 days, or within 24 hours for urgent requests. You can check the status of your grievance by calling your plan or 1-800-MEDICARE. Your State Health Insurance Assistance Program (SHIP) can help you understand when and how to submit grievances. Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted).
It may also be useful to know how to file a complaint about a Medicare Advantage or Part D plan. You can also file a complaint with Medicare if you have an issue with your plan that has not been resolved through the grievance process, or if you want to alert Medicare about other issues with your plan. Medicare has a formal system to handle beneficiary concerns with Medicare health and drug plans. For example, if a plan is not responding to your grievance or appeals by Medicare’s specified deadlines, you should call 1-800-MEDICARE to file a complaint. Your State Health Insurance Assistance Program (SHIP) can also help you submit complaints to Medicare.
If you have a concern about the quality of care you receive from a Medicare provider, your concern can be handled by the Beneficiary and Family Centered Care-Quality Improvement Organization, which is called BFCC-QIO, or just QIO for short. The QIOs are made up of practicing doctors and other health care experts. Their role is to monitor and improve the care given to Medicare enrollees. Some examples of situations about which you might file a quality-of-care complaint include:
Receiving the wrong care or treatment
Experiencing barriers to accessing care
There are two QIOs, Livanta and KEPRO. To find out which QIO serves your state or territory and how to contact them, call 1-800-MEDICARE or visit www.qioprogram.org. You can file a complaint with the QIO over the phone or in writing.
Finally, let’s cover what you should do if you suspect a provider is committing Medicare fraud or abuse. Medicare fraud occurs when someone knowingly deceives Medicare to receive payment when they should not, or to receive higher payment than they should. Medicare abuse involves billing Medicare for services that are not covered or are not correctly coded when the provider has unknowingly or unintentionally misrepresented the facts to obtain payment. Medicare errors are honest mistakes related to the billing of a health care service or item.
You can watch out for fraud and abuse by keeping a calendar of all your medical appointments and comparing it with your Medicare statements and the bills you receive from your providers. If something does not seem right—for example, if you see in your claims summary notice from Medicare that your provider billed Medicare for an office visit on a day when you did not see them—you should first contact your provider. Call your doctor or their billing office and let them know about the problem in case it was mistake.
If your doctor does not fix the error or if you continue to suspect fraud or abuse, you can call your Senior Medicare Patrol (SMP). SMPs empower and assist Medicare beneficiaries, their families, and their caregivers to prevent, detect, and report health care fraud, errors, and abuse. You can contact your local SMP by visiting www.smpresource.org or calling 877-808-2468.
Still have questions?
Your SHIP is here for you! You can contact your SHIP for any other Medicare-related questions or concerns you have. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.) Your SHIP can help with:
Appealing denials of coverage by Original Medicare, Medicare Advantage Plans, or Part D plans
Navigating the grievance and complaint process
Medicare Advantage and Part D prescription drug plan selection and enrollment
Eligibility screenings and enrollment in programs for people with limited incomes, like the Medicare Savings Programs, Extra Help, and State Pharmaceutical Assistance Programs
Questions about what items and services are covered by Medicare
Questions about coordination of benefits between Medicare and other types of insurance, like supplemental policies, Medicaid, and retiree coverage
Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted).
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