Our last post, Trouble Getting Care? File a Complaint, explained how complaints can be used to solve problems with healthcare access when talking to your plan or healthcare provider has failed. This post goes into greater detail about when to consider filing a complaint and which organizations handle which types of complaints.
You should file a complaint if…
1. You Have Trouble Finding Local Providers or Getting Timely Appointments
You should file a complaint If you have you have experienced any of the following:
- You are unable to find a doctor, dentist, psychiatrist, or other healthcare provider that accepts your insurance.
- Your health plan gives you a list of healthcare providers in their network but none of them are available or accepting new patients.
- You find incorrect/outdated information in a directory provided by your health plan.
- Your only option is to see doctors who lack the background, training, and experience to properly treat you.
- You have to wait months–even years–for an appointment.
- You have to drive long distances to appointments.
- Your doctor’s office isn’t open at a time of day that works for you.
If you have experienced any of the situations above, your health plan or health provider may be in violation of state law. You can file a complaint with the health plan and/or the PA Insurance Department. If you have Medicaid and/or Medicare, you should file a complaint to both the PA Insurance Department and the PA Department of Human Services.[/vc_column_text][/vc_column][/vc_row]
PHAN assisted Yvonne H. in filing a complaint to the Department of Human Service. Yvonne’s son Lucas is 32 yrs old and has an intellectual disability, cerebral palsy, and is on the autism spectrum. Lucas is enrolled in the Autism Waiver, a special program that allows him to receive care in his home. However, they live in a rural area and Lucas was not able to get enough support from the local providers who would accept his waiver.
“It’s been a real struggle for me since Luke was placed in Residential. It’s an hour and twenty minute drive one way. This makes keeping him an active part of family life very hard. I feel he is very cut off from what has always been familiar to him. I sincerely wish that sometime in the future more agencies in our area will accept the Autism Waiver and maybe one day families won’t need to be restricted by availability of services.”
Unfortunately, the Department of Human Services was not able to offer a solution and Yvonne eventually arranged for Lucas to be placed in a residential care facility–a decision she had been struggling to avoid making for six years. However, the fact that Yvonne filed a complaint helped PHAN to bring attention to the issue of provider shortages and other issues with the waiver program.
2) You’re Denied Coverage or Services
You should file an appeal with your Health Plan if the plan refuses to pay for healthcare services you need.
If you have been denied Medicare or Medicaid, you should file an appeal with the PA Department of Human Services.
For all other plans, if you think you were denied coverage or services unfairly, you should file a complaint with the PA Insurance Department.
3) You Experience Problems With a Healthcare Facility or Healthcare Professional
If you’re dissatisfied with treatment you received, for example if the healthcare professional you saw was rude and/or unhelpful, or you disagree with the diagnosis or prescribed treatment, you should file a complaint with the facility administration or with your health plan. Larger health systems usually have a patient experience department that can assist you.
If a healthcare professional treated you in a way that was irresponsible or unethical, or if a healthcare professional is practicing outside the scope of their training or without a license, you can file a confidential complaint to the PA Department of State.
If the facility where you received care was unsafe, not physically accessible, or otherwise not operating at an acceptable standard, you can file a confidential complaint to the PA Department of Health.
If you experienced discrimination from a healthcare provider based on race, color, religion, ancestry, age, sex, LGBTQ+ identity, national origin, or disability (including the use, handling or training of support or guide animals for disability), you should should file a complaint to the PA Office of the Attorney General.
We Can Help!
If you have an issue that you haven’t been able to resolve and would like to file a complaint, please contact PHAN’s help line by calling (877) 570-3642.
This publication is funded by the Pennsylvania Developmental Disabilities Council.