For Professionals: Medicare Billing, Claims and Appeals

Got Medicare Complaints? Here’s Your Guide!

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Published: June 2007

With so many entities and contractors involved in the Medicare program, where do you start when you have a complaint to make? Who is the most effective contractor to contact? This is a common question among beneficiaries, family members and advocates alike. And it is an important question. Every Medicare beneficiary has the right to file a complaint, or to register a concern about their health care or health care provider. Making sure people know they have this right AND know how to reach the contractors set up to take action on their complaints is essential for beneficiaries to demand and ensure they receive quality health care. California Health Advocates also encourages beneficiaries to put all complaints and actions taken in regard to any complaint in writing. Having a written record of telephone calls and letters sent to various contractors provide the documentation needed for later follow-up.

Another important resource that is always available to beneficiaries and advocates alike is our California Assembly Members and Senators. Make sure to notify and send a copy of your complaints to them as well.

To help beneficiaries, family members and advocates navigate Medicare’s complaint processes, a list of various types of complaints and where to go for help is shown below.

Topics on this page:

The next newsletter edition will include complaint information regarding Medicare fraud, billings and claims, and Medicare Part D. The Center for Medicare Advocacy (CMA) recently held a conference to discuss the complaint process with regard to quality of care and made several suggestions to improve upon the existing process for beneficiary complaints.

Note that the appeals process (when Medicare does not pay for an item or service a beneficiary has been given, or if a beneficiary is not given an item or service they think they should get) is not discussed here. For more information on Medicare Part A, B, C and D appeals, visit our Medicare billing, claims and appeals section.

Definition of Complaint – a formal or informal procedure to express dissatisfaction with a service, physician/provider, health care facility, insurance agent, and/or health care plan.

The processes for filing complaints discussed below applies to both people with Original Medicare and those in Medicare Advantage plans [Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Special Needs Plans (SNPs), Private-Fee-For-Service (PFFS) plans, Medical Savings Accounts (MSAs) plans]. People enrolled in some MA plans, such as an HMO or PPO, also have access to their plan’s grievance process. A grievance means any complaint or dispute, other than 1 that constitutes an appeal (also referred to as an organization determination), expressing dissatisfaction with any aspect of an MA organization's or provider's operations, activities, or behavior, regardless of whether remedial action is requested. People can also file plan-specific complaints with 1-800-Medicare.

Complaints about:

Care from a Medicare provider/physician:

  • Contact Lumetra, California’s Quality Improvement Organization to file a quality of care complaint at www.lumetra.com; 1-800-842-1602. Call in your complaint and you will be mailed a formal complaint form with a return envelope. Or you can download the complaint form online. Your complaint will be given to a case manager who will contact you usually within 5 days to gather any additional information. Your complaint and medical records are then reviewed by a board certified physician. If a quality of care complaint is verified, Lumetra then contacts your physician and provides education and feedback on ways to improve their quality of care. Depending on the severity of the complaint, some cases are referred to outside agencies such as the California Medical Board or law enforcement. The whole process can be lengthy and take 3 to 6 months. Because of federal law, Lumetra can only tell you the outcome of your complaint if they receive your doctor’s consent.
  • Contact the Medical Board of California under the Department of Consumer Affairs (DCA). The Medical Board is the State agency that licenses medical doctors, investigates complaints, disciplines those who violate the law, conducts physician evaluations, and facilitates rehabilitation where appropriate.

    The Board's staff will review the following types of complaints:
    • the quality of care and treatment provided by a physician (Note: even though Lumetra handles quality of care complaints, filing with the Medical Board is also helpful. While not guaranteed with Lumetra, beneficiaries will be notified about the resulting actions taken from their complaint.)
    • violation of drug laws, misprescribing, or over prescribing
    • substance abuse by a physician
    • sexual misconduct by a physician
    • dishonesty (including filing fraudulent insurance claims)
    • practice of medicine by an unlicensed person or persons under the supervision of a physician

      For information on how to file a complaint, how complaints are investigated, and for a copy of a complaint form, see the Medical Board’s Complaint Information page.

      Contact the Central Complaint Unit at:
      California toll-free line: 1-800-633-2322
      Phone: (916) 263-2424/ Fax: (916) 263-2435
      TDD: (916) 263-0935

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Care from a hospital:

  • Contact your hospital’s ombudsman. Every hospital has ombudsman or patient representatives employed by the hospital to advocate for your care. They can help with the following:
    • Issues with treatment. Disagreements about your course of treatment or time of discharge, or concerns you may have that your patient rights aren't being respected, can all be handled by the ombudsman.
    • Issues with insurance. If your hospital stay and treatment is initially fully covered by insurance, but the insurance provider later indicates that coverage will end sooner than anticipated, or that certain unexpected treatments will not be covered, the ombudsman can help sort out the situation.
    • Changing hospitals. If you are unhappy with the care you are getting, it may be possible to change hospitals. You must have the support of your treating physician to do so, but if that doctor agrees, you may be able to get additional help with the complicated arrangements from the ombudsmen at both your current hospital and the new one. (In most cases, leaving the hospital whenever you want, even against the advice of doctors or hospital staff, is your right as a hospital patient.)
  • Contact Lumetra www.lumetra.com 1-800-841-1602. Like the hospital’s ombudsman, Lumetra also handles quality of care complaints yet provides an outside review versus being handled within the hospital. They also should be contacted if you are given notice that you will be discharged before you feel ready. See the Hospital Patient’s Rights document for more information.
  • When being admitted into the hospital, ask for the notice, “Important Information from Medicare.” This document explains your rights in a hospital and how to make an appeal if you are being discharged before you feel ready to leave.
  • On a side note, see Calhospitalcompare.org for quality of care and comparison information on over 200 California hospitals. Also contains information on hospital preparation tips and patient rights.

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Care in a skilled nursing facility:

  • Contact the facility administrator. Each facility should have written policies readily available that explain how to file a complaint or grievance. Put complaints in writing to the facility administrator and ask for a written response. You can find contact information for the administrator at a specific nursing facility on the California Nursing Home Search website. Enter the facility name in the last box at the bottom of the page.
  • Contact your local Ombudsman Program. Every nursing facility is assigned an ombudsman — a person outside the facility and not associated with the company who is responsible for investigating complaints, reporting allegations of elder abuse (financial, physical, emotional, and mental), and helping residents solve problems through mediation. The Ombudsman Crisis Line is available 24 hours a day, 7 days a week to receive complaints about nursing homes at 800-231-4024. For a list by county, go to the California Long-Term Care Ombudsman Program web site. If your complaint is not resolved, contact DHS.
  • Contact your local Licensing and Certification (L&C) Division of the California Department of Health Services (DHS). DHS is the state agency that enforces nursing home laws and regulations through regular inspections and complaint investigations. You can file a complaint about abuse, neglect and any other matter protected by law. For example, you can file a complaint about violations of your rights, poor care, lack of staffing, unsafe conditions, mistreatment, improper charges, transfer and discharge concerns, and a failure to readmit you after a hospital stay. You can call the L&C program at 800-236-8747.

    You can make a complaint orally or in writing. Again if you phone in a complaint, follow up with a written complaint to ensure a paper trail. The California Advocates for Nursing Home Reform (CANHR) has a sample form to use in filing a complaint. Also, see their site for detailed information on the complaint process, such as what specifics your complaint should include, and complaint follow-up.

    Make sure to notify other agencies of your complaint, ie the Ombudsman program; CANHR; and, as mentioned above your California Assembly Member and Senator.
    • Send the Bureau of Medi-Cal Fraud & Elder Abuse (BMFEA) a copy of your complaint if it involves serious neglect, abuse or Medi-Cal fraud. The BMFEA, a division of the California Attorney General's office, investigates and prosecutes those who abuse and neglect nursing home residents. There are 3 ways to file your complaint: (1) Call it at 800-722-0432; (2) File your complaint on-line at www.ag.ca.gov/bmfea; or (3) Mail a copy of your complaint to the California Department of Justice, Office of the Attorney General, Bureau of Medi-Cal Fraud and Elder Abuse, P.O. Box 944255, Sacramento, CA, 94244-2550.
    • As a side resource to search and compare available nursing homes, visit the California Nursing Home Search website. Medicare also has a Nursing Home Compare website.

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Care from a Home Health Care agency:

  • Contact your home health agency administrator to resolve the issue. All agencies should provide written policies that explain how to file a complaint or grievance. Put your complaints in writing to the administrator and ask for a written response — giving him or her a fair chance to address your concerns.

For more information about possible violations of care guidelines, call the Home Health Hotline at 800-554-0354, a toll-free number established by the state licensing and certification district office to receive complaints or questions about local home health agencies.

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Service from a Durable Medical Equipment (DME) supplier:

  • Call 1-800-Medicare to file a complaint. Staff on the Medicare hotline compile the necessary complaint information and forward it on to California’s Durable Medical Equipment Regional Carrier (DMERC), Noridian for follow-up. Beneficiaries should not call Noridian directly; those who do will be referred back to 1-800-Medicare.

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Services from pharmacists:

  • Contact the manager of the pharmacy, and/or corporate offices and ask about their formal complaint process and where to send in your written complaint.
  • Contact the California Board of Pharmacy. They handle complaints regarding errors in filling prescriptions or suspected misconduct by a pharmacist may violate pharmacy law. The Board does not have jurisdiction over drug prices charged by the pharmacy or prescription billing disputes with insurance carriers.

    You can complete a Consumer Complaint Form found at their website and it send to:
    Board of Pharmacy
    Attention: Enforcement Unit
    1625 N. Market Blvd, Suite N 219
    Sacramento, CA 95834

    To assist the board in evaluating your complaint, provide as many details of the incident as possible. Additionally, include copies of any documentation you may have that relates to the complaint, such as prescriptions, invoices, or correspondence.

    If your complaint is regarding a dispensing error or a prescription container that is incorrectly labeled, keep the container and its contents for future reference, if possible.

    You may also submit your complaint electronically through the Board's ON-LINE COMPLAINT FORM.

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Insurance agents:

  • Complaints regarding agent misconduct in selling Part D insurance plans and MA plans for health benefits involve several agencies, both state and federal. Sales abuses involving Medicare products are a growing problem receiving increasing media attention. Several government agencies are responsible for receiving such complaints.
    • The California Department of Insurance (CDI) –CDI has regulatory authority over agents who sell Medicare products, but not over the Part D and MA plans or the companies that issue these products. Since Medicare is a federal program the Centers for Medicare and Medicaid Services (CMS) retains its authority over the companies and their products. For complaints against agents see the CDI website section on File a Complaint. You can download a complaint form online, print it out, include supporting documentation and mail it to CDI at:

      California Department of Insurance
      Consumer Communications Bureau
      300 South Spring Street, South Tower
      Los Angeles, CA 90013

      If you have no supporting documentation you can file your complaint online. CDI should contact you within 10 business days.

      Call the CDI Consumer Hotline for questions or assistance at: 800-927-HELP (4357); available 8 a.m. to 5 p.m. Monday through Friday.
    • Complaints can and should also be reported to:
      • The respective Part D and MA plans and to 1-800-Medicare; and
      • California Health Advocates' Senior Medicare Patrol (SMP) project. Send a copy of your complaint about an agent to the SMP and they will forward them to MEDIC (the Medicare Drug Integrity Contractor who investigates Medicare Part D fraud and abuse complaints). While MEDIC does not follow up with beneficiaries on these complaints, they do track them for trends of abuse.
    • Contact your local Health Insurance Counseling & Advocacy Program (HICAP) for assistance in filing your complaint. Call HICAP at 800-434-0222 or find your local office online.
  • Misconduct in selling long term care insurance and/or Medigap policies
    • Contact the respective LTCI or Medigap company to report your complaint.
    • Contact the California Department of Insurance (CDI) and follow the steps outlined above.
    • Send a copy of a complaint to California Health Advocates’ so California Health Advocates can monitor developing trends involving certain agents and/or companies.
    • Contact your local HICAP for assistance in filing your complaint: 1-800-434-0222.

See the Medicare Beneficiary Complaints Chart for an easy-to-read summary of this complaint information. Part II of this article in the newsletter’s next edition will include information on Medicare billings and claims, fraud and abuse and Medicare Part D complaints. It will also discuss both the issue of reporting of such complaints back to the public and some recent findings on the services of Quality Improvement Organizations (i.e. Lumetra in California) in an Institute of Medicine (IOM) study.

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