Hopefully you’ll never have a reason to file a complaint or an appeal with Medicare. But one of your rights as a Medicare beneficiary is having the ability to have your complaints heard. There are several reasons why one might file a Medicare complaint and a number of things you should know about the process.
Here we’ll discuss some of the need-to-know information about filing a Medicare complaint and show you how to do it. We’ll also illustrate the difference between Medicare appeals and Medicare complaints.
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Some of the most common reasons for filing a Medicare complaint include:
A beneficiary might file a Medicare complaint over any of the above issues, such as receiving an erroneous bill from a doctor’s office, or for other related situations.
A Medicare appeal concerns an issue with Medicare’s refusal to cover a specific service, device, supply or prescription. You might file a Medicare appeal if you need a certain treatment that Medicare doesn’t typically cover, but you think Medicare should cover it. Filing an appeal doesn’t guarantee that Medicare will cover your treatment or item.
The process for filing a Medicare complaint depends on the type of issue you wish to complain about.
If you have an issue concerning the quality of care you received or the conditions or conduct of a health care facility or provider, contact your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).
To file a complaint about your dialysis treatments or kidney transplant care, you may contact either your ESRD Network or State Survey Agency.
To contact your ESRD Network, call 1-800-MEDICARE (TTY users can call 1-877-486-2048) and follow the prompts to ask for the ESRD Network Organization in your state.
To contact your State Survey Agency, call the phone number associated with your state.
To file a complaint about your durable medical equipment, you may first try contacting the supplier of the equipment to discuss the matter. If nothing is resolved, you may file a formal complaint by calling 1-800-MEDICARE.
Once your complaint is filed, your supplier must contact you within five days to confirm that they received your complaint and are investigating it. They then must send you the result of their investigation and response in writing within 14 days.
If you have a complaint about your Medicare Advantage (Medicare Part C) plan or Medicare Part D prescription drug plan, contact your plan carrier directly or follow the plan’s instructions for filing a complaint located in your plan’s membership materials.
Because these plans are sold by private insurers, each plan may have its own protocol for filing a formal complaint.
You may also submit an official Medicare Complaint Form to file your complaint with Medicare. Medicare uses information from these complaint forms to monitor and improve the quality of private Medicare plans.
Complaints about a Medicare prescription drug plan must be filed within 60 days of the event that led to the complaint, and the beneficiary must be notified of the decision no later than 30 days after filing the complaint.
If the complaint involves a plan’s refusal to make a timely coverage determination and you have not yet purchased the drug as a result of their delay, the plan must grant you a decision within 24 hours of filing the complaint.
Each state has a state health insurance assistance program (SHIP) that provides unbiased assistance to beneficiaries of Medicare and other types of health insurance. The help is offered by volunteers and is free to beneficiaries.
Your local SHIP can help with filing a Medicare complaint. To contact your state health insurance assistance program, visit this page and then select “Find Local Medicare Help” in the upper right-hand corner.
To learn more about the types of Medicare Advantage and Medicare prescription drug coverage options that may be available where you live, you can call to speak with a licensed insurance agent.
While a licensed insurance agent can’t help you with a complaint about your current plan, they can help you compare the costs, benefits, coverage and more for plans that are available in your area.
You can also compare plans online for free, right from the comfort of your own home.
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Christian Worstell is a licensed insurance agent and a Senior Staff Writer for MedicareAdvantage.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.
His work has been featured in outlets such as Vox, MSN, and The Washington Post, and he is a frequent contributor to health care and finance blogs.
Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism. He currently lives in Raleigh, NC.
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