Joel Mekler | Medicare Moments: Medicare complaints, grievances and resources | Lifestyles


Although Medicare provides many excellent health care services, there could also be times when you’re dissatisfied together with your plan’s customer support or the standard of care you received from a Medicare provider. You may have a right to file a criticism (grievance).

A criticism generally is a formal or informal procedure to precise dissatisfaction with a service, physician/provider, durable medical equipment supplier, or health care facility. Complaints can be made against insurance agents and your health plan. It’s necessary to tell apart complaints from appeals. A typical example of once you might file a criticism is when you are displeased together with your Medicare plan’s customer support. Nonetheless, you’ll file an appeal if you’ve an issue together with your plan’s refusal to cover a selected service, supply or drug.

How a criticism is filed relies on the character of the criticism and the way you receive your Medicare-covered healthcare advantages. Let’s take a look at a couple of examples and a few possible remedial actions:

How do I file a criticism concerning the poor quality of my care from my Medicare provider/physician? If you happen to are concerned concerning the quality of care received from a Medicare provider, your concern might be directed to the Beneficiary and Family-Centered Care-Quality Improvement Organization (BFCC-QIO). The BFCC-QIOs are made up of practicing doctors and other health care experts. Their role is to watch and improve the care given to Medicare enrollees. BFCC-QIOs review complaints concerning the quality of care provided by physicians, hospitals, expert nursing facilities, home health agencies, and ambulatory surgery centers.

Examples of situations about which you may want to file a quality-of-care criticism include:

•A medicine mistake

•Developing an infection during a stay in a facility

•Receiving the incorrect care or treatment

•Running into barriers to receiving care.

The BFCC-QIO in Pennsylvania is Livanta, and so they might be reached at (888) 755-5580. Website:

You possibly can file a quality-of-care criticism by calling your QIO or submitting a written criticism. When the BFCC-QIO gets your criticism:

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•They need to call you to ask clarifying questions on your criticism and get your provider’s contact information.

•A physician of matching specialty will review the medical record to find out whether the care provided met the medical standard of care or whether the usual of care was not met.

•You and your doctor might be notified by phone and in writing when the review is over (the review process can take as much as a couple of months).

If you’ve a Medicare Advantage Plan, you may decide to make complaints concerning the quality of care you receive through your plan’s grievance process, through the BFCC-QIO, or each.

You could also contact the Pennsylvania State Board of Medicine to file a criticism about your doctor (like unprofessional conduct, incompetent practice, or licensing questions). The Board approves medical doctors, investigates complaints, disciplines those that violate the law, conducts physician evaluations, and facilitates rehabilitation where appropriate. The Board also regulates physician assistants, radiology technicians, behavioral specialists, and respiratory therapists, to call a couple of.

Moreover, you may contact the Office of the Medicare Ombudsman. To be connected to an ombudsman, call 1-800-MEDICARE and request to be transferred to a member of the ombudsman staff. You possibly can review a physician’s record online regarding past complaints or disciplinary actions taken by visiting or

How do I file a criticism a few Medicare-certified durable medical equipment (DME) supplier? In case your criticism is against a chunk of durable medical equipment, you must contact your supplier directly. The supplier has five days to let they’ve received your criticism and 14 days to report the outcomes of any investigation into the difficulty. Alternatively, when you don’t hear back from the supplier, you might also follow up with Medicare to report the issue.

How do I file a criticism against my Medicare Advantage plan? Medicare Advantage plans are private insurance coverage. While Medicare regulates its advantages and coverage, each plan handles complaints (grievances) internally. You may have 60 days from the date of the incident/concern to file your criticism. You possibly can put your criticism in writing (advisable) or over the phone. You must give you the chance to seek out the suitable contact information in your plan’s membership card or by visiting the plan’s website.

The plan has 30 days to issue a response. Suppose your criticism is concerning the plan’s refusal to make a prompt and favorable determination a few service or prescription drug. In that case, the plan must give you an expedited response in 24 hours. If you happen to are still unhappy together with your plan’s response, contact Medicare at 1-800-MEDICARE.

The Pennsylvania Medicare Education and Decision Insight (PA-MEDI) program may also help assess quality-of-care concerns and judge how one can proceed. Sometimes it’s unclear if an issue should go to the BFCC-QIO, a licensing board, or someone who can handle customer support and billing concerns. PA-MEDI can enable you to sort it out. Contact your local Area Agency on Aging or call the PA-MEDI helpline at (800) 783-7067 from 8 a.m. to five p.m. weekdays.

(Joel Mekler is an authorized senior adviser. Send him your Medicare questions at


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