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 buildingthey 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!

What is the complaint? Who to contact
Improper care & unsafe conditions  State Survey Agency
Hospital conditions  State’s department of health services
Doctor conduct State medical board 

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, which focuses on your plan’s coverage. A complaint is for issues with your plan excluding coverage issues. Your first stop for assistance on coverage should be reaching out to your agent or My Senior Health Plan at 877.255.6273.

You can file a complaint if you have issues with

  • customer service,
  • the availability of specialists,
  • communications about your plan,
  • an appeals process, or
  • the prescription you were given.

For these issues, you can communicate directly with Medicare in writing or over the phone about the issue you’re experiencing. 

If your complaint relates to a specific event, you must file it within 60 days of the event. In general, your plan will notify you of any decision or response within 30 days of filing. But if your complaint relates to your plan’s ability to make quick coverage decisions and you are waiting on prescription medication, you’ll receive a decision within 24 hours of filing. 

Filing a complaint about your quality of care

Issues with the quality of your care are tough. Health issues are scary enough. The added layer of being uncertain whether you can trust the care you’re gettingor worse, knowing you are getting inadequate or harmful treatmenttakes the experience from bad to worse. 

Your quality of care includes a wide variety of concerns. Let’s explore some of the issues you may experience:

  • Prescription issues. You may have received the wrong medication, or been given medications that interact poorly. 
  • Surgical issues. You may have received unnecessary surgery.
  • Treatment issues. You may have been given unnecessary treatment or received no treatment following new developments in your condition.
  • Hospital discharge issues. You may have been discharged from the hospital too soon or without instructions for post-admission care. 

For these issues, contact your Beneficiary and Family Centered Care Quality Improvement Organization. Use this online tool to find your BFCC-QIO.

Filing a complaint about kidney care

If you are having issues specifically with your kidney care, you have more options thanks to End-Stage Renal Disease (ESRD) Networks. ESRD Networks work alongside the State Survey Agencies to handle complaints related to kidney care. 

For concerns about your dialysis or other ESRD care, direct your complaint to your facility or your ESRD Network. They are required to investigate your concern and make sure you understand your rights. Importantly, no one can take action against you for filing. These complaints range from needing to reschedule your dialysis around your work schedule to being treated disrespectfully.

Your State Survey Agency will also deal with complaints about dialysis and transplant centers. These are the folks to reach out to if you are concerned about abuse, incorrect prescriptions or unsafe conditions. Use this tool to find your ESRD Network.

Filing a complaint about medical equipment 

Finally, you might want to file a complaint about a piece of medical equipment. In this case, contact your supplier. You can also call Medicare at 1.800.MEDICARE, or TTY users should call 1.877.486.2048. 

If your medical equipment came through a competitive bidding area, ask your Medicare customer service representative to send you to the Competitive Acquisition Ombudsman. 

After filing, you should expect to hear from your supplier confirming they received your complaint within five days. They’ll then send you a written response with the result of your complaint within 14 days.

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