Things don’t always go according to plan. When unforeseen challenges or mistakes occur, you may wish to know to whom you may voice your concerns and who can help resolve your concerns. For an appeal regarding a denied claim, be sure to review your Medicare Summary Notice (MSN) to submit the appeal in writing. You are also encouraged to call the Medicare Information Office to speak with any of our certified counselors if you need assistance with the appeals process.
Quality concerns
If you have a concern about the quality of care you receive from a Medicare provider, your concern can be handled by the Beneficiary and Family Centered Care-Quality Improvement Organization, which is called BFCC-QIO, or just QIO for short. The QIOs are made up of practicing doctors and other health care experts. Their role is to monitor and improve the care given to Medicare enrollees. Some examples of situations about which you might file a quality-of-care complaint include medication mistakes, receiving the wrong care or treatment, and experiencing barriers to accessing care. Here in Alaska, Kepro is our Medicare contracted QIO; you may contact them over the internet (https://www.keproqio.com) or by calling 888-305−6759.
Formal grievances
A grievance is a formal complaint that you file with your Part D prescription drug plan. A grievance is not the same as an appeal, which is a request for your plan to cover a service or item that has been denied. You may wish to file a grievance if your plan has poor customer service, if your plan takes too long to decide on an appeal, or if your plan fails to deliver a promised refund. To file a grievance, send a letter to your plan’s Grievance and Appeals department within 60 days of the event that led to the grievance. Visit your plan’s website or call the plan for the address. You can also file a grievance with your plan over the phone, but we recommend keeping a written record of the name of the person you spoke to, the date and time of the call, and the outcome of the call. Your plan must investigate your grievance and get back to you within 30 days, or within 24 hours for urgent requests.
Complaints and other issues
You can also file a complaint with national Medicare if you have an issue with your plan that has not been resolved through the grievance process, or if you want to alert Medicare about other issues with your plan. Medicare has a formal system to handle beneficiary concerns with Medicare health and drug plans. For example, if a plan is not responding to your grievance or appeals by Medicare’s specified deadlines, you should call 800-MEDICARE or 800-633-4227 to file a complaint. And you may also call the Alaska Medicare Information Office, as we will be glad to assist in reporting your concern.
Medicare fraud and abuse
Medicare fraud occurs when someone knowingly deceives Medicare to receive payment when they should not, or to receive higher payment than they should. Medicare abuse involves billing Medicare for services that are not covered or are not correctly coded when the provider has unknowingly or unintentionally misrepresented the facts to obtain payment. Medicare errors are honest mistakes related to the billing of a health care service or product.
You can watch out for fraud and abuse by keeping a calendar of all your medical appointments and comparing it with your Medicare statements and the bills you receive from your providers. If something does not seem right — for example, if you see on a claims summary notice from Medicare that your provider billed Medicare for an office visit on a day when you did not see them — you should first contact your provider. Call your doctor or their billing office and let them know about the problem in case it was a mistake.
If your doctor does not fix the error or if you suspect potential fraud or abuse, you can call the Medicare Information Office as one of our certified counselors will be glad to hear your concern and discuss the issue with you.
For answers to any Medicare related questions, please feel free to contact the State of Alaska’s Medicare Information Office at 800-478-6065 or 907-269-3680; our office is also known as the State Health Insurance Assistance Program (SHIP), the Senior Medicare Patrol (SMP), and the Medicare Improvements for Patients and Providers (MIPPA) program.
Sean McPhilamy is a volunteer and Certified Medicare Counselor at the Alaska Medicare Information Office.
