Filing a Complaint Related to Your Healthcare

Many problems can be resolved with a simple conversation. Therefore, we encourage you to share your concerns with your healthcare provider.

Of course, you always have the right to file a complaint regardless of whether or not you discuss the issue directly with your healthcare provider.

If your concern is related to the QUALITY or NECESSITY of care provided, and that care is covered by Medicare—
Please call 1-800-MEDICARE (1-800-633-4227) or TTY/TTD 1-877-486-2048 for the hearing and speech impaired.

Learn more about Medicare's complaint process.

For other all concerns—
We have compiled a list of resources.

What’s Meant by “Quality or Necessity of Care”?

Medicare's review process focuses on concerns related to the quality or necessity of medical care. Examples include preventable situations in which the care caused you harm, or put you in a situation where you could have been harmed, such as:

You received a medication or treatment that you did not need
You were not properly evaluated for a problem, and because of this you did not receive the treatment you needed or the treatment was delayed
You were discharged from the hospital too soon, or with incomplete discharge instructions
You experienced serious complications as a result of care, the lack of care, or because the care was provided in an inappropriate setting (for instance, in a nursing home instead of a hospital)

Medicare's complaint-resolution process does not investigate issues related to unprofessional or impolite behavior, housekeeping, or the temperature of your room or food. For help with these concerns, please see our list of suggested resources.

What to Expect During Medicare’s Quality-of-Care Complaint Process

Medicare has contracted with Qualis Health to respond to Idaho and Washington beneficiaries’ concerns about their healthcare. When you call 1-800-MEDICARE, you will be connected with our helpline if your care was provided in either of those two states.

Our trained staff will talk with you (or your authorized representative) about your concerns and help you decide whether Medicare's complaint-resolution services are appropriate for your case.

We offer the following free services to address the concerns you might have about your care. Each is described in more detail below.

Medical record review
Mediation
Facilitated resolution

To file a formal complaint, you (or your authorized representative) will need to complete a Quality-of-Care Complaint Form. After we have received the completed complaint form, you will be assigned a case manager who will keep you updated throughout the entire process.

Reviewing Your Medical Record
An independent physician (one who does not have a relationship with your healthcare provider or the place where you received care) will review your medical record and determine whether the care you received was similar to what would have been given to you by most healthcare providers. This is called “meeting professionally recognized standards.”

Our decision will be based on the information written in your medical record. We cannot do other kinds of investigation, such as interviews or site visits. If there is not enough information documented in your medical record that relates to your concern, we will not be able to make a decision one way or the other.

If we determine that your care did not meet professionally recognized standards, Qualis Health will work with your healthcare provider to make changes and improve future care.

People with Medicare coverage can help improve healthcare! Read an article describing one man’s experience with Medicare’s review process.

Mediation and Facilitated Resolution
If your case appears to be a good candidate for mediation or facilitated resolution, we may refer both you and your healthcare provider to these services instead of, or in addition to, the medical record review.

Mediation and facilitated resolution provide an impartial, effective means to resolve communication problems.

Mediation may take place over the phone or face-to-face.
In facilitated resolution, the parties do not have any direct contact. All communication occurs by phone or mail and is channeled through the facilitator.

The goal of these methods is to resolve the issue to both parties’ satisfaction. Participation is voluntary.