If a person is not happy with the service he receives from his Medicare Advantage plan, he can make a complaint. This is called a “grievance”. I had a client call me last week with a complaint about his Advantage plan and the process for getting a timely appointment with a podiatrist when he had an open wound on his foot. Les is a diabetic, so a wound that doesn’t heal can get serious quickly. Les seemed to have a valid complaint, so I looked up his plan and how he should file a grievance with the company.
In my research on filing a grievance, I came across a Medicare web page where people can send their complaint to Medicare. Here is the link: https://www.medicare.gov/medicarecomplaintform/home.aspx
A complaint can be made to Medicare, but it should also go to the company. Some companies have an on-line form while others require the grievance to be faxed or mailed to the company. The easiest way to find out how your plan handles grievances is to call the phone number on the back of your Advantage plan id card. It usually says “Member Services”. The person you eventually get on the phone can tell you if there is a specific form to use and where it should be sent.
I have talked to seniors who had complaints about their Advantage plans but were afraid to speak up. They seemed to think they would be penalized if they complained. I tried to assure them this is not the case, because Medicare pays Advantage plans a lot of money and expects them to provide good service.
In the case of my client, Les, I think the problem might have been in the communications between him and the customer service person with whom he spoke. When Les talked to the Member Services representative, did he accurately and thoroughly describe his health problem? Or did the Member Services rep not listen carefully enough to understand Les needed a service the plan is supposed to provide?
I had another client who had a problem with the same company. In Lucille’s case, she needed a referral to see her opthalmologist to get a new prescription for her eye drops. The plan said she could not see her opthalmologist and should see an optometrist instead. Poor Lucille, who is 89, went to the optometrist, paid the $30 co-pay, and was told the optometrist could not write a prescription for her eye drops. When I called the company on behalf of Lucille, I was told the problem was with Lucille’s primary care physician, who probably did not provide the enough detailed information on the referral request. I was told Lucille should explain her situation to Member Services and they would get her an appointment with her opthalmologist.
It all seems rather complicated to me – but the key factor appears to be clearly communicating the reason for a referral to a specialist, or the health issue in the case of Les. And if a person is not satisfied with the answer they get from their Medicare Advantage plan, they need to speak up. Call up Member Services and complain. If that doesn’t work, this is when a grievance can be filed. And that grievance should go to Medicare as well as to the company, so the company fixes the problem.
Grievances and Appeals
There are actually two different issues here: In the case of Les, he was making a complaint about how his Advantage plan served him. This is a “grievance”. In Lucille’s case, she was denied a referral to a specialist, and she could “appeal” this decision made by her Advantage plan. Actually, in Lucille’s case, we didn’t need to file an appeal or a grievance, because the problem was cleared up quickly.
Many issues can be cleared up quickly if you speak up – and this is where your insurance agent should help you. I tell all my clients to call me if they have any problems – as I know whom to call and what to say, and can usually get the problem resolved. And in most cases, the real problem is about communications – on the part of my clients or the Medicare Advantage plan.