Filing A Hospital Grievance: Your Rights And Steps To Take

If you've experienced substandard care or had issues with healthcare providers, it's important to know how to file a hospital grievance. A grievance is an expression of dissatisfaction with any aspect of the operations, activities, or behaviour of a Medicare health plan or its providers. Grievances can be filed for a range of issues, including quality of care, billing, or refusal to cover a service. They can be submitted verbally or in writing, and some organisations may provide specific guidelines or forms for filing. It's important to submit grievances to the appropriate authority or organisation, such as the state medical board, licensing authority, or healthcare facility grievance department. A grievance committee is typically assembled to review the patient's grievance and the hospital's response, aiming for a fair and timely resolution.

Identify the grievance type

When filing a hospital grievance, it is important to first identify the type of grievance. Grievances are expressions of dissatisfaction or concerns about the quality of care or other services received in a hospital or healthcare setting. They can also be related to the operations, activities, or behaviour of a Medicare health plan or its providers.

There are several common types of hospital grievances:

Quality of Care Grievances

These are complaints about the quality of care received in a hospital or other provider settings. This could include concerns about misdiagnosis or delayed diagnosis, medication errors, surgical errors, or other issues related to the standard of medical care provided. Quality of care grievances can be reported through the plan's grievance procedures, the enrollee's Beneficiary Family Centered Care - Quality Improvement Organization (BFCC-QIO), or both.

Plan or Provider Grievances

These are expressions of dissatisfaction about the Medicare health plan or its providers, including concerns about the refusal to cover a service, supply, or prescription; billing issues; or other disputes. Grievances about a plan or provider can be filed directly with the Medicare health plan or through the appropriate state or local organizations, such as the state medical board, licensing authority, or healthcare facility grievance department.

Appeals

An appeal is a request for a review of a previous decision made by the plan, including the denial or limited authorization of a requested service, reduction or termination of a previously authorized service, or failure to render a decision within the required timeframe. Appeals can be filed orally or in writing and must be submitted within specific time frames, typically within 60 days of the decision or incident precipitating the grievance.

Independent Medical Reviews (IMRs)

Members can request an IMR for decisions that the plan denied due to its determination that the therapy or medical service was experimental or investigational. The request for an IMR must be filed within six months of the plan's written response to the member's initial grievance.

It is important to note that the specific grievance types and procedures may vary depending on your location and the healthcare system involved. Always refer to the specific guidelines provided by the hospital, healthcare facility, or Medicare plan for detailed information on identifying and filing a grievance.

Understand the process

Understanding the grievance process is essential before filing a hospital grievance. A grievance is an expression of dissatisfaction with any aspect of the operations, activities, or behaviour of a Medicare health plan or its providers. It is important to note that grievances are not limited to formal written complaints and can also include verbal complaints.

The first step in the grievance process is to identify the appropriate authority or organisation to submit the complaint to. This could be the state medical board, licensing authority, or healthcare facility grievance department. The organisation should provide a complaint form or specific guidelines on their website. It is important to complete the form with all the required information and as much detail as possible, supporting documents such as medical records, bills, or correspondence related to the incident. Keeping copies of all submitted documents is essential for record-keeping.

Once the complaint is received, a grievance committee of qualified individuals will be assembled to review the patient's grievance and the hospital's response. The committee aims to carefully assess the situation, consider all relevant information, and work towards an appropriate resolution. The timeframe for the committee's review may vary depending on the complexity of the complaint and the availability of committee members. However, healthcare facilities generally aim to address grievances promptly to ensure patient satisfaction.

In some cases, the grievance process may involve an independent medical review (IMR) if the plan denied a request due to the therapy or medical service being deemed experimental or investigational. The request for an IMR must be filed within a specific timeframe, and the decision-makers should have the appropriate clinical expertise in treating the patient's condition or disease.

It is important to note that plans must provide meaningful procedures for timely resolution and notify all concerned parties upon completion of the investigation. The timeframe for resolution is generally 30 days after receiving the grievance, but it can be extended in the best interest of the patient.

Know the time limits

Knowing the time limits for filing a hospital grievance is crucial. The Centers for Medicare and Medicaid Services (CMS) set the policies and timeframes for patient grievances, which hospitals are required to follow.

According to CMS guidelines, hospitals must acknowledge and respond to patient grievances within seven days of receiving them. This initial response can be provided in writing or via email. However, it's important to note that this timeframe is for the initial response only and does not guarantee a resolution within that period. The resolution time can vary depending on the complexity of the complaint and other factors.

In California, health plans are required to acknowledge receipt of a grievance in writing within five days of receiving it. This acknowledgement is separate from the actual response to the grievance, which may take longer.

When it comes to appeals, which are requests for a review of a previous decision or a "Notice of Action," there are specific time limits to be aware of. Appeals must typically be filed within 60 calendar days from the date of the notice of action or resolution. However, if the member requests the continuation of benefits during the appeal investigation, the timeframe is shorter, and the appeal must be filed within 10 calendar days.

Additionally, if you are seeking an independent medical review (IMR) after your plan has denied a therapy or medical service, you must file the request within six months of receiving the plan's written response to your grievance.

It's important to note that different states and organizations may have their own specific time limits and procedures for filing grievances. Always refer to the guidelines provided by the relevant authority or organization to ensure you meet the required timeframes.

Who to contact

When filing a hospital grievance, it is important to identify the appropriate authority or organization to contact. The specific entity will depend on the nature of your complaint and your location. Here is a step-by-step guide on who to contact when filing a hospital grievance:

Identify the Appropriate Authority or Organization

Common options include the state medical board, licensing authority, or the healthcare facility's grievance department. For instance, if you are in California, you can refer to the California Health & Wellness website for guidance on the grievance process. Alternatively, if your grievance pertains to Medicare, you can contact 1-800-MEDICARE (1-800-633-4227) for assistance. This service offers live chat and phone support 24 hours a day, seven days a week, except on certain federal holidays.

Contact the Relevant Department or Entity

Once you have identified the appropriate authority or organization, you should contact them to understand their specific procedures and requirements for filing a grievance. They should be able to provide you with a complaint form or detailed guidelines on their website. It is important to carefully follow their instructions and provide as much detail as possible when submitting your complaint.

Seek Legal Advice (Optional)

If you encounter complexities during the complaint process or are unsure about the appropriate authority to contact, consider seeking legal advice. Consulting with a medical malpractice attorney can help ensure that your complaint is properly filed and navigate any legal intricacies. They can also guide you in determining the relevant authority to approach, depending on the nature of your grievance.

Appoint a Representative (Optional)

If you wish to have a family member or friend assist you with your complaint, you can appoint them as your representative. This can be particularly helpful if you feel you need additional support or advocacy throughout the grievance process.

It is important to note that the specific contacts and procedures may vary based on your location and the specifics of your grievance. Always refer to the guidelines provided by the relevant authority or organization for the most accurate and up-to-date information.

What to include

When filing a hospital grievance, it is important to include detailed information about the incident that caused your dissatisfaction. Here is a list of what to include when filing a hospital grievance:

Details of the Incident:

Provide specific information about the incident that led to your grievance. Include dates, times, and locations, as well as the names of any individuals involved, such as medical staff or witnesses. Describe the events that took place and explain why you are dissatisfied with the care or services you received.

Supporting Documents:

Attach any relevant supporting documents to your grievance. This may include medical records, bills, correspondence, or any other documentation that relates to the incident. Keep copies of all submitted documents for your own records.

Nature of the Grievance:

Clearly state the nature of your grievance and what aspects of the hospital's operations, activities, or behaviour you are dissatisfied with. This could include quality of care issues, billing disputes, refusal to cover services or supplies, or any other specific concerns you may have.

Previous Attempts at Resolution:

Include information on any previous attempts you have made to resolve the issue. This could be informal conversations or communications with hospital staff or other relevant parties.

Desired Outcome:

Explain what outcome you are seeking by filing this grievance. Are you requesting a refund, an apology, improved policies, or specific changes to be made? Be clear about what actions you would like the hospital to take in response to your grievance.

It is important to note that the grievance process may vary depending on your location and the specific hospital or healthcare facility involved. Be sure to review the grievance procedures of the relevant organization and seek legal advice if needed to ensure your grievance is properly addressed.

Frequently asked questions