Complaints About Medicare
In This Chapter
- Your right to express concerns to Medicare
- What constitutes a grievance
- When and how to file a claim
- Understanding the five levels of appeals
Health care is an expansive topic unto itself, and Medicare’s web of rules and regulations adds an extra layer of complexity to it. No one is perfect and the U.S. government is no exception. It is not surprising that errors sometimes creep into the network. If you disagree with services provided by or declined by Medicare, you have a right to voice your concerns. This chapter outlines how you should proceed in different scenarios to hopefully swing things in your favor.
Filing a Grievance
We live in a world where customer service reigns supreme. If you feel that your health-care experience has been inappropriate in any way, you have a right to speak up and file a complaint. These complaints are referred to as grievances.
Depending on the type of grievance, there may be different protocols to follow. Most grievances can be placed by contacting 1-800-MEDICARE or by filling out the Medicare Complaint Form online at medicare.gov/MedicareComplaintForm. There is an option available to expedite reviews of your complaints if needed. Medicare will determine if the case warrants expedition and will usually tell you within 24 hours if it will be able to speed up the process in your case.
Customer Relations
You deserve to be treated with respect at all times. Human dignity depends on it. If someone has been rude or you do not feel you have been treated fairly, such behavior must be addressed to prevent it from happening again. Sexual harassment or discriminatory conduct against age, race, gender, or sexual orientation also fall under this category. This applies whether you were treated this way by a health-care provider, a receptionist, or even custodial staff. Anyone who works in a facility where you receive health care must be appropriate in their interaction with you.
Location, Location, Location
You may have concerns about a facility (i.e., hospice center, hospital, nursing home, skilled nursing facility) where you received care. Overall cleanliness of a facility may be an issue, or you may be put at risk by hazardous conditions or poor security. Electrical hazards, water damage, fire safety issues, poor temperature control, and even poor quality of food preparation at a given facility are all examples of how location can have an impact on your overall health-care experience. These issues may be remediated if brought to the attention of the proper authorities.
Each of these facilities has a designated official, known as an ombudsman, assigned to address and remediate patient concerns. Your grievances may first be placed with the ombudsman, and then with Medicare if further attention is required.
Quality of Care
While the previously covered issues are indeed important to your health-care experience, they do not inherently relate to the actual quality of medical care you receive. Grievances about the quality of care you receive are addressed through Quality Improvement Organizations (QIO).
The QIO Program is run by CMS and is responsible to assure that the care you receive meets certain standards of care, medically and professionally. In the past, each state had its own QIO, but concern had been raised about conflicts of interest due to ongoing relationships between facilities and their state-run organizations. For this reason, CMS restructured and streamlined the QIO program to improve efficiencies and to reduce undue influence by outside parties. These changes took effect on August 1, 2014.
QIOs have been redefined, now referred to as Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIO). The 50 states, District of Columbia, and certain U.S. territories have been divided into five discrete areas. Two contractors have been hired to address the needs of patients in their assigned areas.
The first company, Livanta (livanta.com), based in Maryland, covers quality of care concerns for Alaska, Arizona, California, Connecticut, Hawaii, Idaho, Maine, Massachusetts, Nevada, New Hampshire, New Jersey, New York, Oregon, Pennsylvania, Puerto Rico, Rhode Island, Vermont, U.S. Virgin Islands, and Washington. The second company, Ohio-based KePro (keproqio.com) addresses the remaining U.S. states as well as the District of Columbia. Aside from Puerto Rico and the U.S. Virgin islands, no other U.S. territories have CMS-regulated BFCC-QIO coverage.
Quality of care issues should be voiced to the BFCC-QIO in your state or U.S. territory or to Medicare directly. Common complaints addressed by a BFCC-QIO may include but are not exclusive to the following:
- You are unable to get an appointment within a reasonable amount of time.
- You are made to wait an excessive amount of time at your appointment.
- You were not offered appropriate treatments.
- You were offered and/or given treatments that were not necessary.
- You suffered complications from a failed treatment or surgery.
- You were prescribed the wrong dose, strength, or frequency of a medication.
- You were prescribed a medication that is contraindicated in your situation, either based on allergies you have or based on interactions you could have with your other medications.
- You were given the wrong medication at the pharmacy.
- You were released too early from the hospital.
A formal BFCC-QIO review follows a careful procedure to assure the case has been reviewed from all angles.
- Receipt of a written complaint. You are required to submit your complaint in writing; a telephone call alone will not suffice. The BFCC-QIO will acknowledge receipt of your complaint in writing. It is all about leaving a paper trail.
- Medical record request. In order to determine whether or not you received appropriate care, your medical records need to be reviewed. You will need to sign a release form so that this information can be accessed by the BFCC-QIO. If your health-care provider fails to release the required medical information as requested, there could be serious repercussions. Medicare could even cancel their contract agreement with your provider so he can no longer participate in the program.
- Quality case review. Your case is reviewed by the BFCC-QIO. An initial determination will be made as to whether or not your grievance warrants further investigation. If the treatment you received followed appropriate standards of care, the case may be closed at this stage. You will receive documentation about the decision and investigation.
- Re-review process. If Medicare believes quality care was not rendered, your health-care provider will be contacted and allowed to add additional documentation for review. This essentially becomes his opportunity to defend himself.
- Notice of disclosure. Medicare will notify your health-care provider of their decision based on all information received. Your provider is offered a final opportunity to comment and can decide whether or not to allow the BFCC-QIO to disclose his documentation to you, the claimant. Not disclosing documentation is not a sign of wrongdoing.
- Response to claimant. You will receive the final case report outlining any findings by the BFCC-QIO and their plans to rectify the grievance.
As you can see, the process is thorough but could take considerable time. You would not want someone to breeze through the case and not give it proper attention. That said, you do not want it to take too long. If the case is concurrent, cases may be processed over 38 to 83 days. If a case is retrospective, cases could take as long as 85 to 165 days to complete. These estimates predate the establishment of the BFCC-QIO program.
DEFINITION
Concurrent cases are related to health care that you are currently receiving. For example, you are staying in a facility and receiving treatment. Retrospective cases are related to health care you have received in the past, and the course is completed. You are no longer staying in the facility, and you are no longer receiving that specific manner of treatment. Concurrent cases are seen as more urgent given there may still be time to make changes to care you are currently receiving.
Cases that were begun prior to August 1, 2014, under state-run QIOs should have been forwarded to the appropriate BFCC-QIO for final processing. If you placed a grievance during that time and are not sure if it is receiving proper attention, you may contact Livanta or KePro accordingly to address your concerns.
Kidney Disease
Kidney disease is increasing not only in the United States but worldwide. Grievances related to treatment of kidney disease can be placed in many ways. Concerns may range from quality of care to scheduling issues. Though you may report your grievances to your health-care facility or to Medicare directly, local End-Stage Renal Disease Networks have also been established to address patient concerns about care you receive at dialysis or kidney transplant centers. State Survey Agencies once worked in concert with these networks but have since been replaced by BFCC-QIOs.
When you file a grievance about a dialysis center you can choose to remain anonymous, but even if you do not, you will not face any repercussions from the facility if you continue to receive care there. That would be illegal.
Medical Equipment
Durable medical equipment could be damaged or even be inappropriate to your situation. Such equipment may also be unfairly expensive when compared to equivalent offerings through other agencies. If you have received equipment or supplies that you feel do not meet quality standards, you must report your grievance to the supplier within five calendar days. They must respond to you with a written response, and hopefully a solution, within 14 days of receiving the initial complaint.
If the supplier does not follow this protocol, you may report it to Medicare or your BFCC-QIO to address your concern. A Medicare representative may then forward your grievance to the Competitive Acquisition Ombudsman (CAO) as needed to address the issue.
Medicare Advantage and Part D
Grievances for Medicare plans run by private insurers follow a different timeline. For Medicare Advantage and Part D plans, you have 60 days from the time of the inciting event to place your concern with the insurance company. Your grievance must be reviewed and addressed within 30 days.
Each private insurance company will have their own protocols on how to address grievances. If your concerns are not reconciled as expected, you may contact Medicare in writing or by telephone at 1‒800‒MEDICARE.
Filing a Claim
Being a patient is hard enough without you needing to send your own bills to Medicare. In the majority of scenarios, your health-care provider will send bills to Medicare on your behalf. Exceptions may occur under rare circumstances, but they do occur. Know how to proceed so that you are not shortchanged in the end.
In order for Medicare to pay their share of any services you receive, they need to receive claims in a timely manner. If they don’t, you are on the hook for the whole payment. Claims must be filed within one calendar year from when you received the service. For example, if the service was rendered on July 11, 2014, your provider has until July 11, 2015, to file the claim.
DEFINITION
A claim is a bill to Medicare or other insurance provider requesting payment for services provided.
You pay your premiums for a reason. Make sure you get your full money’s worth.
Delayed Filing
Your provider may not have an efficient billing department, in which case they may delay sending claims to Medicare for processing. This can be problematic in many ways.
Your health-care provider can still bill you the amount that Medicare would have expected you to pay if the claim had been filed on time. This is usually a 20 percent coinsurance for Part B services. If you have not not yet spent the amount on your deductible that year, you could also be billed that dollar amount as well.
If a claim is not filed, Medicare will not acknowledge that you already paid money toward your deductible, even if the services would have been covered. This means you will still have to pay that amount toward your deductible when you need another service in the future. You want to make sure Medicare credits any money you spent out-of-pocket on your deductible. They can only do this if there is a proper claim on your record.
CAUTION
Claims are processed faster by Medicare when they are sent by your health-care provider. It is in your best interest to nudge your provider to file the claim before you send one in yourself.
The best you can do is call your provider to request they process the claim. If worse comes to worst, you may have to file the claim yourself. You may contact 1‒800‒MEDICARE or access the Patient’s Request for Medicare Payment form, also called the CMS-1490S form, at cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS012949.html. There are detailed instructions on how to process the claim available in both English and Spanish. You will need to have copies of all bills and receipts for the care you received in order to proceed.
Nonparticipating Providers
Your health-care provider may accept Medicare for payment, but he may not accept all the bells and whistles. If you have selected a nonparticipating provider as your care giver, you may be put at higher risk for sending your own claims to Medicare.
As discussed in Chapter 16, nonparticipating providers agree to accept Medicare for payment but do not accept assignment. Accepting assignment means that the provider does not agree to part or any of the Medicare Fee Schedule. This allows him to bill you more than the Medicare recommended amount for certain or even all services. In this case, he may or may not choose to send those claims to Medicare. This would leave you responsible to get the necessary information to Medicare for processing.
If you are on Original Medicare, participating providers are required by law to submit claims on your behalf for any covered services.
Advanced Beneficiary Notices
Advanced Beneficiary Notices (ABN), discussed in Chapter 11, protect both you and your provider financially. If your health-care provider thinks there is a chance Medicare will not pay for a certain test or service, he must notify you of this before the test is performed by having you sign this ABN. This protects the provider because he has it in writing that you agree to cover the costs of any service not covered by Medicare. This protects you, because if you are not asked to sign an ABN for a service that is not covered by Medicare, you are not liable to pay for any charges associated with that service.
Because your provider thinks Medicare might not cover something does not mean that it is necessarily true. Medicare could surprise you! It is always worth submitting a claim because without a claim in effect, you do not even have the option to appeal a decision. It could well be the case that you could make a strong argument to have a certain test covered. The appeals process is discussed later in this chapter.
There is a check box on the ABN form asking whether or not you want your provider to submit a claim to Medicare for that service. Always check YES. Otherwise, your provider, whether they are participating or nonparticipating, does not have to submit a claim for services it does not believe Medicare will cover. Make your life easier. Have your provider do the leg work.
Medicare Advantage and Part D
You will never file a claim with Medicare for a Medicare Advantage or Part D plan. This is because Medicare pays those private insurance companies on a monthly basis already. If you have to file a claim, it will be through the insurance company directly. Each company may have their own policies in place regarding how to submit claims.
While each insurer will be different, it is not uncommon for you to come across this issue when accessing out-of-network providers. If you receive care from a provider who does not have a direct affiliation with your insurance company, they may charge you directly for any services rendered, and you will have to submit claims for the insurance company to make payments to that provider or to reimburse you if you paid for that care out-of-pocket. In-network providers generally submit claims on your behalf.
If You Suspect Fraud
If a participating provider refuses to bill Medicare for covered services and requires you to pay out-of-pocket for services before your appointment, you should be on high alert. Put simply, your provider should not be asking you to pay what Medicare would pay. This is against the law and sanctions could be taken against that provider.
You should contact Medicare immediately to address any concerns you have about suspicious billing activity by your provider. You may also need to notify administrators at the facility where the provider works, the state medical licensing board, the state Attorney General’s office, and even your local Medicare Administrative Contractor (MAC). CMS provides an interactive list of MACs by state on their website.
The Appeals Process
Though both are types of complaints, an appeal is different than a grievance because it addresses the financial as opposed to the technical aspects of your care. If you feel that Medicare ought to cover a test but this coverage was denied, you can file an appeal. Likewise, if you feel that Medicare did not pay enough toward the cost of a service or test, you can appeal. You have a right to express your concerns. The process can be quite lengthy and requires you to be thoughtful in gathering your documentation.
DEFINITION
An appeal is a complaint made against Medicare or other insurance provider when you disagree about what should be covered and paid for under your health plan.
The Medicare appeals process is divided into five stages. Each stage is summarized in the following pages. Differences will be addressed as they apply when appealing to Original Medicare or another Medicare Health Plan.
Level 1: Redetermination and Reconsideration
After your provider (or, if you’re unlucky, you yourself) sends a claim for Original Medicare, it is reviewed by a Medicare contracting company to determine whether a service will be covered and for how much. You will receive the determination on your Medicare Summary Notice (MSN). As discussed in Chapter 17, you receive MSNs quarterly.
If you disagree with the initial determination, you may place a Level 1 appeal. Information on how to place an appeal will be clearly outlined on your MSN. You only have 120 days to appeal a decision after you receive the MSN. The same Medicare contracting company will review your case but a different individual will be assigned to look at the information.
CAUTION
Make sure Medicare has your most up to date address. If an MSN is sent to the wrong address, you may not receive the document in a timely manner, if at all, and may not be eligible to make an appeal on your case within the allotted time.
A Level 1 appeal for a Medicare Advantage Plan is referred to as a “request for reconsideration” and must be placed within 60 days of the plan declining coverage. You will hear back from the insurer in 30 to 60 days depending on whether your appeal addressed a requested service or payment concern. If your case is denied at this level, your appeal will be automatically bumped to Level 2.
Similar to a Medicare Advantage Plan, a Level 1 appeal for a Part D plan, a “request for redetermination,” must be placed within 60 days. Turnover is much faster with a decision made within seven days. If your case is denied a second time, your appeal will be automatically bumped to Level 2.
Level 2: Independent Contractors
Whereas private Medicare plans are automatically forwarded to a Level 2 appeal, you must decide on your own whether to continue the appeal process for Original Medicare. This is referred to as a “request for reconsideration.” The lingo becomes confusing as this is the same phrase used to define Level 1 Medicare Advantage appeals.
For Original Medicare, you have 180 days after receiving your Level 1 determination to make a Level 2 appeal. At this stage, the Medicare contracting company is now replaced by a Qualified Independent Contractor (QIC) who hires health-care professionals available to review the medical necessity of your case. The process for appealing and contacting the QIC will be clearly outlined on your Level 1 determination letter. A decision should be made by the QIC in 60 days.
For a Level 2 review, you want all your ducks in a row. You need to write a letter explaining why you are making a complaint and the reasons why you feel the service or charges should be covered. You want to have any additional supporting information forwarded to the QIC for review at this time. It may be difficult to add this information at later levels of appeal unless there are extenuating circumstances.
ROUND TABLE
Thomas’ claim for laboratory studies to investigate a possible diagnosis of rheumatoid arthritis was denied coverage by Medicare. Since he uses Original Medicare, he filed an appeal within 120 days, and his case was reviewed by the Medicare contracting company that first saw his case. Unfortunately, his claim was not deemed medically necessary, and he appealed to a Level 2 Qualified Independent Contractor within 180 days. Because his health-care provider forwarded additional information, including a detailed letter, on his behalf, Medicare approved the coverage of these tests, leaving Thomas to only pay his usual coinsurance.
Private Medicare health plans use an Independent Review Entity (IRE) to determine medical necessity at this stage. For Medicare Advantage, Level 2 appeals are called a “reconsidered determination” and for Part D a “request for reconsideration.” For Medicare Advantage, you should receive a result within 60 days, and for Part D within 7 days.
Level 3: Hearing
Regardless of the type of Medicare plan you have, all Level 3 appeals are processed the same and must be submitted in writing. There is no automatic entry into this stage. You must actively appeal the case within 60 days of your Level 2 determination, and you can only proceed if there is $140 or more in debate. The requisite dollar amounts may change over time. This value is from 2013.
This level requires that you present testimony before an Administrative Law Judge (ALJ) at a hearing. Experts in a given field may also be asked to testify. Your hearing will take place via video-teleconference (the majority), telephone, or in-person. In the case where the findings are clearly in your favor, a hearing may not be required at all. That said, it rarely occurs that your case would have been denied this far into the appeals process if it were really a slam dunk.
You will be notified at least 20 days before the hearing. Once you are notified of the hearing date, you must respond within 5 days that you accept the assigned date. After the hearing, you will receive a determination within 90 days, though again the deadline could be extended depending on the case.
Level 4: Medicare Appeals Council
If your Level 3 appeal was denied, you have 60 days from receiving your hearing results to advance to a Level 4 appeal under the Medicare Appeals Council (MAC). There is no contested dollar threshold required to enter this stage of appeals.
CAUTION
This is where abbreviations go wrong. Medicare Administrative Contractors and the Medicare Appeals Council are both MACs. When you see these abbreviations, keep them in context.
The MAC is part of the Department of Health and Human Services and is not associated with the ALJ as this would be a conflict of interest. After reviewing all the testimony from your hearing, a determination will be made about your case in 90 days though, again, extended deadlines may occur.
Level 5: Taking It to the Courts
Sixty seems to be the magic number for Medicare appeals. You have 60 days to apply for a Judicial Review by a Federal District Court if your Level 4 claim is denied, but you may only proceed to this level if the contested amount is at least $1,400 using 2013 data.
After this, there is no further action you can take. If your case is denied at Level 5 (or even Level 4 if you did not meet qualifying dollar amount to enter Level 5), you will be responsible for any payments charged to you.
Expediting Your Case
There may be situations where you cannot sit around waiting for an answer on your appeal. While we may all feel that way, there are specific situations that may expedite your request. If you are actively receiving or requiring the care in question and your medical health is at immediate risk, your case may be expedited. This is the case for both Original Medicare and private Medicare health plans, but expedition can only occur at Levels 1 and 2. The process for expedition will be outlined in your appeal forms.
The Least You Need to Know
- You have a right to express concerns about any experience you had with your health care, medical or nonmedical.
- A Medicare claim must be filed within one calendar year of the service provided.
- If a claim is not filed with Medicare, you will not get any credit for any money you may have spent toward your deductible.
- Nonparticipating providers do not have to submit claims to Medicare on your behalf but participating providers do.
- If you disagree with Medicare’s decision not to cover or pay for certain services, you can appeal their decision using a five-level process.