Having access to health care is incredibly important, both to help make you better when you’re sick or hurt and to try to prevent health issues down the road. The Medicare program is a popular health care option for people who are eligible to enroll, but even then, things aren’t always perfect. You may love your plan, but have an issue with some of the health care you’ve received. If this sounds like you, you may be able to file a insurance grievance to try and resolve your issue. So, what exactly is a grievance and how do you file one? Let’s find out!
What is a Medicare Grievance?
The Centers for Medicare & Medicaid Services (CMS) considers a grievance to be an expression of dissatisfaction with your Medicare insurance plan or covered health care provider. The openness of this definition is designed to give beneficiaries the ability to have a greater say in their health care and their coverage. Some examples of groups or individuals you can file a Medicare insurance grievance against, should you need to, could include:
- Your Medicare insurance plan;
- A health care provider;
- A health care facility;
- Or a durable medical equipment (DME) provider.
Generally, the complaint will be about the quality of care, service, or coverage you’re receiving, ensuring you have the ability to rectify mistakes with your health care. For example, let’s say a pharmacy gives you the wrong medications. You could file a grievance to have that fixed. Also, if you notice your plan isn’t following CMS guidelines or is sending you bad information, you can also file a grievance to get that corrected. You can even file a grievance if your plan isn’t following the appeals process correctly or you take issue with the plan not granting requests for fast appeals or fast determinations.
Medicare Insurance Grievances vs. Appeals
Now that we’ve mentioned the appeals process, you may be wondering, what’s the difference between the two? Both are used to give beneficiaries a voice in their coverage, and both are used as ways to rectify issues you have with your coverage or care. So, why are there two? You can define the difference by focusing on what the complaints are about. For Medicare insurance appeals, the complaint is about your Medicare insurance coverage, or more specifically, what’s not covered. Medicare insurance grievances cover the quality of your health care and Medicare insurance coverage.
It’s important to know the difference between Medicare insurance grievances and appeals, so should you run into issues, you know where to turn.
A practical example of this would be from our medication example above. If a pharmacy gives you the wrong medication or a medication that interacts poorly with another drug you’re taking, you’d file a Medicare insurance grievance. If your Medicare insurance plan doesn’t cover a specific drug that you feel it should, you’d file a Medicare insurance appeal. It’s important to know the difference between the two, so should you run into issues, you know where to turn.
How to File a Grievance
Let’s say you do run into an issue and need to file a grievance. First, any complaint must be filed within 60 days of the event and issue. The grievance can be filed verbally (as in a phone call) or in writing. Once the grievance has been filed, the Medicare insurance plan must provide procedures toward a meaningful and timely resolution to all interested parties. When the investigation has been completed, the plan must notify each party of this completion no later than 30 days after the original grievance was received.
Of course, should you need additional assistance, you can talk to your State Health Insurance Assistance Program (SHIP).
Depending on what you’re filing a complaint about, where you turn may differ. Here a some examples:
- For issues with durable medical equipment (DME), you can consult the equipment’s producer or call 1-800-MEDICARE.
- Quality complaints about a health care provider can be filed through the Beneficiary and Family Centered Care Quality Improvement Organization.
- For issues arising from End-Stage Renal Disease (ESRD) care, you can talk to ESRD Networks or State Survey Agencies.
- Complaints about your Medicare insurance plan, can be handled by filling out the Medicare insurance complaint form to get started on your grievance.
Of course, should you need additional assistance with addressing any issue with your health care, you can talk to your State Health Insurance Assistance Programs (SHIP).
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Ultimately, a Medicare insurance grievance gives beneficiaries a powerful voice in the quality of their Medicare insurance coverage and their health care. If you’re experiencing issues with your health care, don’t be afraid to use the tools at your disposal to file a Medicare insurance grievance. You deserve to have high-quality health care, and the grievance process is one way that you can protect your right to quality care.
