Paul Sanchez
Medicare insurance is a federal program that provides health coverage to millions of Americans, and like any large program, issues can arise that require intervention. If a Medicare enrollee has concerns about the quality of care they are receiving, they can turn to the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO or QIO). QIOs are made up of medical professionals who are tasked with monitoring and improving the care given to enrollees. If an enrollee suspects fraud or abuse, they can contact their Senior Medicare Patrol (SMP), which assists beneficiaries and their families in preventing, detecting, and reporting these issues. Medicare enrollees can also contact their State Health Insurance Assistance Program (SHIP) for free, personalized health insurance counseling.
| Characteristics | Values |
|---|---|
| Who to contact | Medicare Beneficiary Ombudsman |
| Phone number | 1-800-MEDICARE (1-800-633-4227) |
| TTY number | 1-877-486-2048 |
| State programs | State Health Insurance Assistance Programs (SHIPs) |
| SHIP phone number | 877-839-2675 |
| SHIP website | www.shiphelp.org |
| Quality-of-care concerns | Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO or QIO) |
| QIO phone number | 1-800-MEDICARE |
| QIO website | www.qioprogram.org |
| Medicare fraud or abuse | Senior Medicare Patrol (SMP) |
| SMP website | www.smpresource.org |
| SMP phone number | 877-808-2468 |
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What You'll Learn
Contact the Medicare Beneficiary Ombudsman
If you have a Medicare-related complaint, grievance, or information request, you can contact the Medicare Beneficiary Ombudsman (MBO). The MBO was established in 2003 to assist Medicare beneficiaries with their inquiries, complaints, and requests for information. They ensure that you have access to information about your Medicare rights and protections and understand how to resolve your concerns.
You can contact the MBO if you have been unable to resolve your concern with your plan or 1-800-MEDICARE. Ask a 1-800-MEDICARE representative to submit your complaint or inquiry to the MBO, who will ensure that your inquiry is appropriately resolved. TTY users can call 1-877-486-2048.
State Health Insurance Assistance Programs (SHIPs) are also available to help with Medicare-related complaints and inquiries. SHIPs are state programs that offer free, local health insurance counseling to people with Medicare. They are not connected to any insurance company or health plan and can provide personalized counseling to help resolve your concerns. You can find your local SHIP at https://www.shiptacenter.org/.
If you need to file a claim, appeal, or complaint, you can do so through the appropriate channels. If you need to request payment for a Medicare service or item, you can usually file a claim. If you disagree with a coverage or payment decision, you can file an appeal. If you have concerns about the quality of your care or other services, you can file a complaint. Additionally, if you need someone else to file a claim, appeal, or complaint on your behalf, you will need to fill out an "Authorization to Disclose Personal Health Information" form, which can be downloaded in Spanish.
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File a claim or appeal
It is rare to have to file a claim or appeal for Medicare, but it is possible to do so. If you need to request payment for a Medicare service or item, you can usually file a claim. If you disagree with a coverage or payment decision by Original Medicare, your Medicare health or drug plan, you can file an appeal. If you have concerns about the quality of care or other services, you can file a complaint.
How to File a Claim
If you need to request payment for a Medicare service or item, you can file a claim. This is usually only necessary in very rare cases. You can file a claim anonymously, and the method for doing so will depend on the type of claim.
How to File an Appeal
If you disagree with a coverage or payment decision by Original Medicare, your Medicare health or drug plan, you can file an appeal. Generally, there are five levels of appeals, and you will receive a decision letter at each level with instructions on how to move to the next level. The appeals process varies based on the kind of coverage you have. If you need to file an appeal, refer to the decision letter you received from the MAC at level 4 for instructions on how to proceed. You can also contact Medicare for help by calling 1-800-MEDICARE (1-800-633-4227) or chatting with a live agent 24 hours a day, 7 days a week (except some federal holidays). TTY users can call 1-877-486-2048.
How to File a Complaint
If you have concerns about the quality of your care or other services, you can file a complaint. You can file a complaint anonymously, and the method for doing so will depend on the type of complaint. You can also contact your local State Health Insurance Assistance Program (SHIP) to get free, personalized health insurance counseling. Visit shiphelp.org to get the phone number for your local SHIP.
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Complain about improper care or unsafe conditions
If you have a complaint about improper care or unsafe conditions in a hospital, home health agency, hospice, or nursing home, you can contact your State Survey Agency for more information. If you have concerns about the quality of your care or other services, you can file a complaint or a grievance. You can also contact the Medicare Beneficiary Ombudsman, who can help you with Medicare-related complaints, grievances, and information requests. They will ensure that you have Medicare rights and protections information and understand how to get your concerns resolved. If your concern hasn't been resolved by Medicare or your plan, you can ask the Medicare Beneficiary Ombudsman to review your case by calling 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
State Health Insurance Assistance Programs (SHIPs) are state programs that receive federal funding to provide free, local health insurance counselling to Medicare enrollees. SHIPs can help you with free, personalized counselling to resolve your concerns. You can visit shiphelp.org to get the phone number for your local SHIP.
If you are covered by Medicare or by a Medicare-managed care plan, you can file an appeal about a discharge while you are still in the hospital. You should receive a form from the hospital titled "An Important Message from Medicare," which explains how to appeal a hospital discharge decision. Appeals are free and usually resolved within two to three days. The hospital cannot discharge you until the appeal is completed.
If you have received poor medical care in a hospital, you can contact your state's Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for complaints about the quality of care from a Medicare provider. You can submit a complaint to your BFCC-QIO for issues such as receiving the wrong medication, undergoing the wrong surgery or treatment, or being discharged too early. You can also file a complaint with the Joint Commission, which certifies many U.S. hospitals' safety and security practices and investigates complaints about patients' rights.
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Contact your State Health Insurance Assistance Program (SHIP)
State Health Insurance Assistance Programs (SHIPs) are state programs that receive funding from the federal government to offer free, local health insurance counselling to Medicare beneficiaries and their families. SHIPs are not affiliated with any insurance company or health plan. They provide personalized counselling to help with Medicare-related complaints, grievances, and information requests. SHIPs also assist beneficiaries with limited incomes to apply for programs such as Medicaid, the Medicare Savings Program, and Extra Help/Low Income Subsidy, which help to reduce healthcare costs.
The Medicare Beneficiary Ombudsman can help you with Medicare-related complaints and ensure that you have the information you need to resolve your concerns. If your concern hasn't been resolved by Medicare or your plan, you can call 1-800-MEDICARE (1-800-633-4227) to submit your inquiry to the Medicare Beneficiary Ombudsman. TTY users can call 1-877-486-2048.
ACL's Office of Healthcare Information and Counseling (OHIC) manages SHIP. They work with state offices, local agencies, grantees, and community providers to establish community-based networks of counselors who provide assistance in person and over the phone. SHIP is a national program that offers one-on-one assistance, counseling, and education to help Medicare beneficiaries, their families, and caregivers make informed decisions about their care and benefits.
SHIPs were established under the Omnibus Budget Reconciliation Act of 1990. This legislation authorized the Centers for Medicare & Medicaid Services (CMS) to provide grants to states to create and maintain health insurance advisory service programs for Medicare beneficiaries. These grants fund information, counseling, and assistance activities related to Medicare, Medicaid, and other health insurance options. In 2014, SHIP was transferred from CMS to ACL, reflecting the existing collaborations between the SHIP programs and the networks served by ACL.
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Report Medicare fraud or abuse
Medicare fraud and abuse can occur anywhere and often result in higher healthcare costs and taxes. It is important to know how to spot and prevent Medicare fraud and abuse. You should compare the dates and services on your calendar with your Medicare statements to ensure you received each listed service and that all the details are correct. It is also important to protect your personal information and be aware of how Medicare uses it. Before joining a Medicare health or drug plan, you should understand how your personal information will be used. You can also learn about recent scams and stay vigilant.
If you suspect Medicare fraud, you can call 1-800-MEDICARE (1-800-633-4227) or report it online. Alternatively, you can contact the Investigations Medicare Drug Integrity Contractor (I-MEDIC) at 1-877-7SAFERX (1-877-772-3379) if you have a Medicare Advantage Plan or Medicare drug plan. When reporting suspected fraud, it is helpful to have as much information as possible, such as any relevant dates, services, and personal information that may have been compromised.
In addition to reporting fraud, you can also file a complaint if you have concerns about the quality of your care or other services you receive. If you have Original Medicare and want to inquire about your benefits or costs, you can call 1-800-MEDICARE. For those with a Medicare health or drug plan, it is recommended to contact your plan first. You can also reach out to your local State Health Insurance Assistance Programs (SHIPs) for free, personalized health insurance counselling. These programs are not affiliated with any insurance company or health plan and can provide impartial assistance.
If you feel your rights have been violated, you can contact the Medicare Beneficiary Ombudsman, who can help with Medicare-related complaints, grievances, and information requests. They ensure that you understand your Medicare rights and protections and can assist in getting your concerns addressed. The Ombudsman can be reached by calling 1-800-MEDICARE, and they will guide you through the process of resolving your issue.
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Frequently asked questions
You can contact the Medicare Beneficiary Ombudsman to help with Medicare-related complaints, grievances, and information requests. They can be reached at 1-800-MEDICARE (1-800-633-4227).
Your concern can be handled by the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO or QIO for short). QIOs are made up of practicing doctors and other healthcare experts who monitor and improve the care given to Medicare enrollees. You can file a complaint with the QIO over the phone or in writing.
You can first contact your provider and inform them of the problem. If the issue is not resolved, or you continue to suspect fraud or abuse, you can call your Senior Medicare Patrol (SMP). SMPs assist Medicare beneficiaries and their families in preventing, detecting, and reporting healthcare fraud, errors, and abuse.
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