Make a Complaint About a Medicare Advantage Plan

Your patient has a Medicare Advantage plan and tells you he can no longer see you because you are not considered in-network with the plan. Or you are contracted with the plan but experiencing delays in obtaining pre-authorization services. What do you do?

You can file a complaint if you have a concern about the quality of care or other services you get from a Medicare Advantage program. A complaint is about the quality of care you got or are getting. For example, a patient may not think there are enough specialists in the plan to meet his medical needs. Or perhaps he believes the Medicare Advantage plan is not following Medicare coverage guidelines.

A Medicare beneficiary or provider may file a complaint about the health plan within 60 days from the date of the event that led to the complaint. Medicare offers an online complaint form, which can be accessed here.

The following information should be included with your complaint:

• Name, address, and telephone number of person filing the complaint
• Name of the insurance company
• Name of person insured
• Policy number and Claim number (if applicable)
• Date of occurrence
• A brief description of why the complaint is being filed

You may also contact your state's department of insurance for further assistance. Find links to the appropriate state complaint forms here.

What does this mean for you?

There are established methods for filing complaints against the insurance companies' policies and you should take advantage of these opportunities. Fight for your patient and for your profession. Every complaint is and may lead to changes in overall coverage policies or operational procedures.