How Can I File a Complaint with Medicare?
Summary: You can file a complaint if you feel any of your rights under Medicare have been violated. A complaint is different from an appeal for a payment decision.
If you’re enrolled in any Medicare plan, you have certain Medicare rights guaranteed by the government. For example, you have
- The right to privacy,
- The right to be treated fairly,
- The right to be protected against unethical practices, and
- The right to receive any health care services you need as allowed under the law.
These rights cover you whether you’re enrolled in Original Medicare, a Medicare Advantage plan, a Medicare Supplement insurance plan, or a stand-alone Medicare Part D Prescription Drug Plan.
Sometimes, however, you may believe your rights were violated by a health care provider. When that happens, you also have the right to contact Medicare and file a grievance or complaint. Here’s what you need to know in order to contact Medicare and have your complaints addressed.
Is there a difference between a Medicare complaint and an appeal?
Yes, and it’s important to know which issue you’re addressing before you contact Medicare. A complaint deals with things such as:
- You have a problem with how your doctor treated you.
- You aren’t happy with the quality of your care.
- You believe a hospital or other facility treated you unfairly.
- You aren’t satisfied with the quality of your durable medical equipment.
- Your plan’s customer service department was unable to answer your questions.
An appeal, on the other hand, deals specifically with your plan’s refusal to pay for services, durable medical equipment, or prescription medications. This article discusses how to contact Medicare to file a complaint; if you want to file an appeal, the process is a bit different.
How do I contact Medicare to file a complaint against my doctor or hospital?
Complaints against a health care provider fall into four basic categories:
- Complaints of abuse or unsafe conditions,
- Complaints about physical hospital conditions such as poor housekeeping or lack of heat or air conditioning,
- Complaints about unprofessional conduct, or
- Complaints about your quality of care, such as prescription drug errors, unnecessary procedures, or poor discharge planning and follow up care.
The first three issues are generally handled by your state’s health department or medical board. In these situations, you should not contact Medicare but go directly to the state agency responsible for overseeing health practices and facilities.
If you have a quality of care complaint, you should contact Medicare to connect with your local Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). This is the organization charged with handling Medicare complaints about the quality of care for beneficiaries.
How do I contact Medicare to file a complaint about durable medical equipment (DME)?
If you have a complaint with your Medicare DME, your first step is to contact your DME supplier. The supplier has five days to let you know they have received your complaint, and 14 days to report the results of any investigation into the issue.
You should also contact Medicare at 1-800-MEDICARE and report the issue. TTY users should call 1-877-486-2048. If the supplier doesn’t resolve it to your satisfaction, you may be able to file an appeal or take additional action against the supplier.
How do I contact Medicare to complain about my Medicare Advantage or Part D Prescription Drug Plan?
Medicare Advantage and Medicare Part D prescription drug plans are private insurance plans. Although they are regulated by the Medicare program in terms of benefits, coverage, and Medicare rights for enrollees, each plan handles complaints internally within the company.
Medicare rules for complaints against Part D prescription drug plans state that you have 60 days from the date of the incident you’re complaining about to contact your plan and file a complaint. You can either write to the insurance company or contact them by phone. You should be able to find the appropriate contact information on your insurance card or in your plan brochure.
Once the plan receives your complaint, it has 30 days to respond. If the complaint deals with the plan’s refusal to make a prompt and favorable determination about a service or prescription drug, the plan must respond within 24 hours.
If you are unhappy with your plan’s response, you have the right to contact Medicare and file an appeal. You can also get in touch with your local BFCC-QIO if the issue relates to quality of care.
In all cases, your State Health Insurance Assistance Program (SHIP) is available to help you contact Medicare or file a complaint. Help from your state SHIP is always free to Medicare beneficiaries.
To look for a Medicare Advantage, Medicare Prescription Drug, or Medicare Supplement insurance plan in your area, enter your ZIP code on this page.