Wednesday, March 29, 2017

Dispute Resolution

Opthamologist sitting on chair.

The Orange County Medical Association is the advocate for physicians, patients, and the highest quality health care for our community. 

As a patient and a consumer, there may be times when you’re dissatisfied with the care you are receiving – whether by a personal physician, hospital, or your insurer. Some problems can be resolved informally simply by talking to the parties involved, but others will require that you follow an official set of "grievance procedures.” It’s important to try and resolve a problem, particularly when it affects your health. Depending on the issue, there are many independent organizations that can assist in difficult situations.

Patient Complaint/Peer Review Panel –

Before filing a complaint, it is necessary that you personally discuss the issue with the physician before OCMA can assist in resolving any dispute.  This procedure generally resolves most problems.

A patient may file a complaint against a doctor in writing.  The matter will be referred to OCMA’s Patient Complaint/Peer Review Panel.  The Patient Complaint/Peer Review Panel will thoroughly review the matter and if deemed valid, recommend commensurate action.

The panel has no authority to revoke a medical license, to set fees, or to discipline physicians.  OCMA has no power to require you or your physician to accept its advice.

To file a complaint, please write a letter outlining your complaint, including the physician’s name, address and phone number as well as the patient’s name, address and phone number, and mail it to OCMA Patient Complaint Peer Review Panel, 17322 Murphy Avenue, Irvine, CA  92614. 

Questions may be directed to ocma@ocma.org or by calling (949) 398-8100.
Please note: This is a confidential, peer-review advisory process; disciplinary action can only be taken by the Medical Board of California (MBC). To file a complaint with the MBC, call (800) 633-2322 or visit http://www.mbc.ca.gov/.

Patient Complaints with Hospital and Inpatient Facilities

If you're having a problem with a hospital or other health care facility, the first step is to contact their "patient complaint coordinator." If you do not get a satisfactory response and would like to take further action, the government agency responsible for licensing and regulating hospitals is the California Department of Public Health (CDPH). To file a complaint with CDPH, fill out the online consumer complaint form. You may also contact the CDPH Licensing and Certification District Office at (800) 554-0354.

Patient Complaints with Health Plans

If you have a problem with your health plan, you have the right to file a complaint. A complaint is also called a grievance or an appeal. The rules and procedures for filing a complaint will vary based on the type of plan. Contact your health plan for information on accessing the plan’s formal dispute process. If you then do not get resolution, and depending on what type of health insurance you have, there are two state agencies with which you can file a complaint against your health plan:
The Department of Managed Health Care (DMHC) regulates all HMOs, plus Blue Shield of California PPO and Anthem Blue Cross of California PPO. These plans are subject to regulation under the Knox-Keene Act. To file a complaint, contact DMHC’s Help Center at (888) HMO-2219, TDD (877) 688-9891 or visit the DMHC website.
You can also contact DMHC by mail at:

Department of Managed Health Care
Help Center
980 9th Street, Suite 500
Sacramento, CA 95814-2725

Patient Complaints with Health Insurers

PPOs (except Blue Cross and Blue Shield PPOs) and other non-HMO insurers are regulated by the Department of Insurance (DOI). DOI investigates complaints, prosecutes insurers when appropriate and responds to complaints and inquiries by members of the public concerning the handling of insurance claims or alleged misconduct by insurers.
 
If you have a complaint about a health insurer, the first step is to contact the insurance company in an effort to resolve the issue. If you need help with a grievance involving an emergency or that has not been satisfactorily resolved by your insurer, you may contact DOI for assistance at (800) 927-HELP (4357), TDD (800) 482-4833 or by completing an online complaint form.

You can also contact DOI by mail at:
California Department of Insurance
Consumer Communications Bureau
 300 South Spring Street, South Tower
 Los Angeles, CA 90013

Medicare Patient Grievances

Medicare patients are entitled to special grievance and appeal rights. Medicare HMOs, competitive medical plans, and health care prepayment plans are required by law to give you a complete written explanation of your grievance and appeal rights. The Medicare website, www.medicare.gov, is also helpful.  Information on appeals can be found at www.medicare.gov/basics/appeals.asp.
 
HICAP (the Health Insurance Counseling & Advocacy Program) provides free and objective information and counseling about Medicare. Volunteer counselors can help you understand your specific rights and health care options. Contact HICAP at 1-800-434-0222 or www.cahealthadvocates.org/HICAP.

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