Quality of Care Complaints
 Medicare and CCME want to make sure your care meets established standards and guidelines. You or your designated representatives can request a free review of your medical record if you have concerns about the quality or necessity of medical care you have or are receiving. Everyone with Medicare has this right, including those with a Medicare Advantage Plan, such as an HMO. This type of complaint is called a “grievance” if you are enrolled in a Medicare Advantage Plan.
Examples of quality of care concerns you might report to CCME are:
- Receiving a medical procedure in an inappropriate medical setting (i.e., you received a surgery as an outpatient but should have been admitted into the hospital).
- Receiving a medication or medical service that could have or did cause harm.
- Suffering a serious injury resulting from a fall while in a nursing home or hospital.
- Being improperly evaluated for a problem and, as a result, not receiving the treatment you needed.
- Being given the wrong treatment or treatment that you did not need.
- Developing bed sores due to poor skin care.
Some examples of quality of care concerns that CCME is unable to address are:
- Billing issues, insurance coverage questions or concerns, Medicare Advantage plans questions/concerns.
- Attitudes, rudeness of staff or physicians.
- “Environmental” concerns in hospitals or nursing facilities, etc (dirty facility, broken equipment, lack of staff, unsafe conditions/staff, or bad food).
- Obtaining medical records or medical treatment.
For more information on what are not considered quality of care concerns and appropriate contact numbers, please download CCME’s “Issues the QIO (CCME) can not address” document.
Why file for a quality of care review?
The purpose of a quality of care review is to find the reason underlying the cause of your concern and to determine the likelihood that it will happen again. The purpose of a quality of care review is not to punish your health care provider, but to help improve care for future patients.
Who to Call?
Call Medicare at 1-800-MEDICARE (1-800-633-4227) or TTY/TTD 1-877-486-2048, if you do not think you are getting good care, or if you did not get good care, from one of the following health care providers:
- Hospital
- Hospital emergency department
- Skilled nursing facility
- Rehabilitation facility
- Ambulatory surgery center
- Doctor's office
- Home health agency
During this call, you will be asked questions that allow CCME to better understand your concern. If you decide you want to make a formal complaint, you will be asked to send your concerns to CCME in writing. Once we receive your formal, written complaint, CCME will begin the quality of care review process.
For more information on visit Medicare’s website to download a free Frequently Asked Questions publication to answer your questions further.
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