The Medicare Complaints Process

The Medicare Complaints Process
Urban Institute Research Report; by Laura Skopec, Avani Pugazhendhi, Judith Feder; 9/13/24
The Medicare complaints process allows beneficiaries to file complaints or grievances about the quality of the services they receive from Medicare plans, including issues with enrollment, customer service, or the ability to use their benefits. The US Department of Health and Human Services also funds State Health Insurance Assistance Programs (SHIPs) to provide in-person and telephone support to beneficiaries in their local area who need help enrolling in or using their Medicare coverage, including filing complaints... To explore how the Medicare complaints process works, we held three roundtables with SHIP staff, beneficiary advocates, and provider associations to identify issues and opportunities in the Medicare complaints process and possible paths for improvement... Our roundtable participants identified three primary groups of issues with the Medicare complaints process:

1. Many beneficiaries, SHIPs, and other assisters have difficulty navigating the Medicare complaint process through to resolution.
2. SHIP staff, beneficiary advocates, and provider association representatives were all unclear on CMS processes for resolving complaints, how complaint data is used internally, and how CMS uses complaints to hold Medicare plans accountable.
3. Roundtable attendees noted that Medicare consumer assistance programs lack sufficient resources to effectively help beneficiaries navigate complex enrollment, appeal, and complaint processes without adequate assistance.

Suggested Approaches to Improve and Expand the Medicare Complaints Process:

• Reduce beneficiary barriers to filing complaints.
• Reduce barriers to complaint assistance.
• Improve transparency and accountability.
• Continue refining oversight and rulemaking to address abuses identified via complaints.
• Consider establishing an online complaint form for providers to identify systemic issues that may be occurring across multiple beneficiaries.

Finally, we further encourage Congress to appropriate additional funds for consumer assistance in Medicare to support enrollment assistance and help resolve complaints and grievances.
Publisher's note: In light of recent hospice complaints, this is an important report on how such complaints are heard, tracked, and resolved (or not). The full report can be downloaded here.