Tuesday, August 21, 2018

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.

Medical Board of California 

The Medical Board is responsible for reviewing and investigating complaints about, and disciplining licensed physicians & surgeons.

The Board's staff also reviews and investigates complaints about Doctors of Podiatric Medicine and Physician Assistants; however, any disciplinary action taken against one of these licensees is decided by the licensing Board/Bureau for that profession.

If an individual or organization appears to have violated the laws within the Board's jurisdiction, Board staff will investigate the allegations and charges may be filed. Following are the types of complaints reviewed by the Board:

Substandard Care (e.g., misdiagnosis, negligent treatment, delay in treatment, etc.)
Prescribing Issues (violation of drug laws, excessive/under prescribing)
Sexual Misconduct
Impairment (drug, alcohol, mental, physical)
Unlicensed practice, or aiding and abetting unlicensed practice
Unprofessional Conduct (e.g., breach of confidence, record alteration, filing fraudulent insurance claims, misleading advertising, arrest or conviction)
Office Practice Issues (e.g., failure to provide medical records to patient, failure to sign death certificate, patient abandonment)

Except for special circumstances, complaints must be filed in writing. Written complaints may be submitted to the Board’s Central Complaint Unit by mail, via fax, or online. For further information regarding the Board’s complaint review process, contact:

Central Complaint Unit
Toll-Free: 1-800-633-2322
Phone: (916) 263-2382
Fax: (916) 263-2435        
Website:  http://www.mbc.ca.gov/.

California Office of the Patient Advocate

Includes information on filing complaints against health plans and providers. More information may be found here http://www.opa.ca.gov/Pages/ProblemsAndComplaints_TalkingWithYourDoctor.aspx.

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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