Medicare Service Gone Wrong? When and How to File a Complaint

We all wish the healthcare system was perfect. No one wants to deal with a doctor making the wrong recommendation, unpleasant or unsafe hospital conditions, the wrong prescription, or inappropriate treatment. 

Unfortunately, the reality is that these issues do happen. And when they do, you may feel that letting someone know is important. You might need your care to be readdressed or want an explanation for why you need to switch doctors or pharmacies. The closure of knowing someone hears your negative experience, and to hopefully prevent the situation from happening again, is also healing.

So when your Medicare experience isn’t what you want (or need), you might find yourself filing a complaint. The process of filing a complaint with Medicare can be a little tricky, and how you navigate this task depends on the subject of your complaint. In this article, we’ll walk you through who to call in some specific situations and the basics of how to file. 

Is a complaint the same as an appeal? 

The short answer: no. You file an appeal when you have a problem with your plan, usually if coverage for a service or prescription is denied. Filing an appeal is a separate process to help you find possible solutions. 

A complaint isn’t about the coverage itself. Your focus is the care you’re getting (or not getting). Complaints are centered around how you’ve been treated, doctor recommendations, prescription issues or equipment issues.

Let’s dive into how you can file a Medicare complaint based on the type of issue you’re having. 

Filing a Medicare complaint about a provider 

The conditions of a doctor’s office or treatment center matter. If you live in an assisted living community, water damage, asbestos, or the lack of a clear fire safety plan, probably make you feel unsafe.  

Safety hazards don’t just include the building—they are also created by staff members. Improper care, like concerns for abuse, must be reported. 

Your State Survey Agency, which is usually part of your state’s department of health services, handles complaints about unsafe environments and improper care. A complaint can be filed about an assisted living center, hospice, home health agency or doctor’s office. 

If you encounter unsafe or unpleasant conditions at a hospital, you’ll need to direct your complaint to your state’s department of health services. You can file a complaint for issues like a hospital’s food, temperature, or cleanliness.

Finally, you may need to file a complaint about your doctor. If they behaved unprofessionally, seemed incompetent, or you aren’t sure about their licensing, go to the state medical board.

Here’s a quick breakdown of what we’ve covered to help you identify the next person to talk to!

As always, if you’re having a problem with your healthcare plan, or if you have questions about coverage, you can contact your agent or My Senior Health Plan.

Filing a complaint about your healthcare or drug plan

Sometimes your Medicare plan isn’t quite working for you. Remember, a complaint is different from an appeal. If you have a problem with your Medicare Advantage, Medicare Part D (prescription drug) plan, or your Medicare Supplement plan, you need to understand the difference. You file a complaint if the quality of care disappoints you or you are having trouble getting the services you need. An appeal would be for when you want Medicare to cover a service it denied.

A complaint might also be about your plan’s enrollment process, members’ rights, or if you received misleading information about the plan. If you aren’t sure, contact your state’s Health Insurance Assistance and Counseling Program (SHIP) for assistance.

If your plan provides Part D prescription drug coverage, you can file a complaint if you have issues filling a prescription, paying for your medication, or if you feel your plan’s formulary (the list of covered drugs) is not paying for a prescription it should. When in doubt, you can also contact 1-800-MEDICARE.

Medicare assigns a 5-star rating each year to all plans. You can also check out your plan’s star rating to see if it ranks well compared to other plans.

Navigating complaints and Medicare

We know the Medicare complaint process is confusing. With different procedures in place for a myriad of potential issues, making the right call is tricky. Plus, you’re trying to figure this out on top of your existing health or safety concerns.  

To learn more about your Medicare plan or if your experiencing issues with your plan, contact My Senior Health Plan. Get in touch with us at 877.255.6273.

image credit: shutterstock/Bricolage

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Pete Blasi

President/CEO at My Senior Health Plan

Pete Blasi, the driving force behind My Senior Health Plan and the prestigious Financial Grade Senior Consultants, has been at the helm of both since their inception in 2005. Under his leadership, these well-known and respected organizations have thrived to become renowned full-service Medicare consulting and brokerage firms with a nationwide presence.

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