Got a Complaint?
What should you do if you have a complaint about your physician, hospital or health plan?
California Medical Association
If you have had medical services or prescription drugs denied by your HMO or other health plan, please read this to get an idea of what recourse for appealing that denial is. If you do not live in California, you can still try the same things, but do check with your own state medical association, state insurance commissioner, and/or board of consumer affairs.
As a health care consumer, there may be times when you are unhappy with your physician, hospital, or health plan and need to make a complaint. Some problems can be resolved informally simply by talking to the parties involved, but others will require that you follow an official set of "grievance procedures". The following guidelines explain what to do and who to contact for more information.
If not, here are a couple other things you can do: If your physician is a member of the California Medical Association, you can discuss your problem with the medical society in the county where the physician practices. The society will arrange for other physicians, and possibly a mediation committee, to study the problem. Physicians who are CMA members are required to go through this dispute resolution process if a patient requests it. Click here for a list of county medical society phone numbers and websites.
If your doctor is not a CMA member, or you want to take additional action, you can contact the California Medical Board's Central Complaint Unit at 1-800-633-2322 or (916) 263-2424. The Medical Board will start an investigation, and if necessary, submit your case to the California Attorney General. The Medical Board is the organization that licenses physicians, surgeons and other health care providers. They are the only group that has the authority to take away a physician s license.
If you want to take further action, you might contact a representative of your health plan. Health plans want you to be happy with the care you are getting under their coverage and are often willing, to help you solve any problems you may be experiencing.
You can also contact The Joint Commission on Accreditation of Healthcare Organization. The Joint Commission, along with the California Medical Association, conducts surveys to be sure that hospitals are providing quality care. Ask them to investigate your complaint. You can reach them through their website or call them at (630) 792-5000.
The government agency responsible for licensing and regulating hospitals is the California Department of Health Services (DHS). To file a complaint, you need to contact the district office in the area where the hospital is located.
About Health Plans
The California Medical Association has worked to make it possible for patients to solve their problems with health service plans, including HMOs, in a faster, less complicated way. We recently sponsored a new law that lays out grievance procedures that can be used for any concern, for example a charge that your health plan refused to pay or an instance when you had to wait an unreasonably long time to see a doctor.
These instructions will take you through the process of filing a complaint and tell you what to expect along the way. You'll want to follow somewhat different guidelines if your problem is an emergency.
Step One: Write
a Letter to Your Health Plan
Here is a sample letter you may wish to use as a guide (Download text verion):
Dear Sir or Madam:
The purpose of this letter is to inform you of my problem with ___________ [Explain the problem you are having].
My complaint concerns______________ [the reason for your complaint]. In order to solve my problem, I would like _____________ [the specific action you want the plan to take].
I look forward to your reply and a resolution of my complaint.
Enclosures [Include copies of all related records. Do not send originals.]
Step Two: Complete
Your Plan's Complaint Process
Step Three: Contact
The Appropriate Agency
In order to know which agency to contact, you will need to find out whether your plan is an HMO or a traditional insurance plan. You can ask your employer, a plan representative, or the California Department of Corporations (DOC), the agency that regulates health care service plans (their toll-free number is 1-800-400-0815). You can also look for the information in your insurance papers in a section called the "Evidence of Coverage Statement". (Complaints about Medi-Cal and Medicare are handled by other agencies.)
If you have traditional insurance, you will need to take your complaint to the California Department of Insurance and fill out a Request for Assistance form. You can reach them through their website or by calling their consumer hotline at 1-800-927-HELP.
If you have an HMO, Blue Cross, or Blue Shield, you will need to contact the Department of Corporations (DOC) at 1-800-400-0815. (If you are hearing or speech impaired, call 1-800-735-2929 (TTY) or 888-877-5378 (TTY).
The DOC requires that you go through your plan's grievance process before they will help you. Plans governed by the DOC must try to make a decision on complaints within 30 days. If it's been 60 days since you filed a complaint, and your plan still hasn't resolved the problem, or if you don't like the plan's response, the DOC will help you.
When you contact the DOC, they will send you a complaint form to fill out. Then they will study your case and possibly request more information or hold an informal meeting with the parties involved. In most cases, all parties will receive a letter explaining the DOC's decision within 60 days.
Under the law, your doctor can assist you as you go through the complaint process. You can request that your doctor attend any informal meetings requested by the DOC.
Keep in mind that if your plan requires that you resolve problems through arbitration, you still have the option of going to the DOC beforehand. You also have the right to take legal action or go to a mediator (if the plan agrees) without going through the DOC first.
If you have traditional insurance, call the California Department of Insurance at 1-800-927-4357 and explain your situation. If necessary, they will contact your insurance company by phone to resolve your complaint, instead of going through their usual process, which commonly takes from 30 to 90 days.
Where To Send Complaints
Board of California
Department of Health Services (DHS)
About HMOs, Blue
Cross, or Blue Shield
About Traditional Health Insurance Companies
Medi-Cal Public Inquiry
Department of Health Services
for Medicare & Medicaid Services
HEALTH CONSUMER ADVOCACY GROUPS
General health plan issues:
Senior citizen health insurance issues:
Health Insurance Counseling
and Advocacy Program (HICAP)
for Health Care Rights (serves Los Angeles County)
Health plan disclosure to patients:
for the "Right to Know"
The information on this page was excerpted from http://www.cmanet.org/publicdoc.cfm/14/4.
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