Navigating the Health Care System

Advice Columns from Dr. Carolyn Clancy

Former AHRQ Director Carolyn Clancy, M.D., prepared brief, easy-to-understand advice columns for consumers to help navigate the health care system. They address important issues such as how to recognize high-quality health care, how to be an informed health care consumer, and how to choose a hospital, doctor, and health plan.

Whether it's a car repair that didn't fix the problem or a bad meal in a restaurant, many of us don't hesitate to complain. Making our voices heard when something isn't right is the first step in getting it corrected. But when we're sick or need health care services, it's hard to know where to direct a complaint. And it can be difficult to question people who may know more than we do, especially when we aren't feeling well.

These reasons are valid, but they shouldn't be obstacles. As a physician, I'm encouraged that consumers are becoming more comfortable asking their medical team questions. I hope this continues.

Hospitals and health groups have tried to make it easier for patients to raise concerns or complaints. But it's still not easy to do. Health services are delivered in many different settings and are often not coordinated from one place to the next. So it's up to the patient or his or her family to identify where to make a complaint and to follow through and report the problem.

A very helpful Government resource, called the Beneficiary Ombudsman, is available for people covered by Medicare or Medicare health plans. This Web site can serve as your first stop to learn how these and other Government programs work and how to file a complaint or an appeal.

People who are covered by private insurance should review the information they get when they enroll to find out who to contact when they have complaints.

Here are some resources for complaints or concerns that arise:

While you are in the hospital: If possible, first bring your complaints to your doctor and nurses. Be as specific as you can and ask how your complaint can be resolved. You can also ask to speak to a hospital social worker who can help solve problems and identify resources. Social workers also organize services and paperwork when patients leave the hospital.

If you are covered by Medicare, you can file a complaint about your care with your State's Quality Improvement Organization (QIO). These groups act on behalf of Medicare to address complaints about care provided to people covered by Medicare.

Typical complaints QIOs handle are getting the wrong medication, having the wrong surgery, or receiving inadequate treatment. You can also find your QIO by calling 1-800-MEDICARE.

If you get an infection while you are in the hospital or have problems getting the right medication, you can file a complaint with the Joint Commission. This group certifies many U.S. hospitals' safety and security practices and looks into complaints about patients' rights. It does not oversee medical care or how the hospital may bill you.

To find out what other patients had to say about their recent hospital stays, visit the Hospital Compare Web site. You'll find answers from patients about how well doctors and nurses communicated, how well patients' pain was controlled, and how patients rated their hospital.

If you are discharged before you're ready: This is a big concern for many patients because insurers balk at long hospital stays. Talk to the hospital discharge planner (often a social worker) if you don't think you're medically ready to leave the hospital. The discharge planner will take your concerns to the doctor who makes this decision.

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 get a form from the hospital titled "An Important Message from Medicare," which explains how to appeal a hospital discharge decision. Appeals are free and generally resolved in 2 to 3 days. The hospital cannot discharge you until the appeal is completed.

When you get your hospital bill: First, ask your doctor or the hospital's billing department to explain the charges. Find out how the hospital handles complaints about bills, and make your case. If you still have questions, you should contact the Medicare carrier that handles billing issues for your Medicare program.

You can also call 1-800-MEDICARE about billing questions. Make sure you have the date of service, total charge in question, and the name of your doctor and hospital.

Even with this information, it's not easy to be as assertive in a health care setting as it is in an auto repair shop or restaurant. But it's a smart move that can help you get the quality care that you deserve.

I'm Dr. Carolyn Clancy and that's my advice on how to navigate the health care system.

More Information

Agency for Healthcare Research and Quality
Questions Are the Answer: Get More Involved With Your Health Care

American Health Quality Association
Quality Improvement Organization (QIO) Locator
http://www.ahqa.org/pub/connections/162_694_2450.cfm

The Joint Commission
Report a Complaint about a Health Care Organization
http://www.jointcommission.org/report_a_complaint.aspx

Department of Health and Human Services
Beneficiary Ombudsman: Inquiries and Complaints
http://www.medicare.gov/Ombudsman/resources.asp

Department of Health and Human Services
Hospital Compare—A Quality Tool Provided by Medicare
http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp

Department of Health and Human Services
Medicare Appeals and Grievances
http://www.medicare.gov/basics/appeals.asp

Department of Health and Human Services
Helpful Contacts
http://www.medicare.gov/Contacts/Include/DataSection/Questions/SearchCriteria.asp

Current as of March 2009
Internet Citation: How To Complain - And Get Heard. March 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/columns/navigating-the-health-care-system/031709.html