Medicare Compliance & Reimbursement

Question: One of the providers in our Medicare Advantage (MA) plan received a grievance. We are confused. Do we appeal that? Is it a denial?

North Carolina Subscriber

Answer: First, know that a grievance is not a claims denial. A Part C grievance refers to a beneficiary’s complaint.

“A grievance is an expression of dissatisfaction (other than an organization determination) with any aspect of the operations, activities, or behavior of a Medicare health plan, or its providers, regardless of whether remedial action is requested,” the Centers for Medicare & Medicaid Services (CMS) explains in MA guidance. “The enrollee must file the grievance either verbally or in writing no later than 60 days after the triggering event or incident precipitating the grievance.”

For example, a beneficiary might file a grievance if they can’t get in to see their respective provider through their managed care plan. Another reason a Part C provider might receive a grievance is due to rude or disrespectful behavior, CMS says.

Timeline: All Medicare managed health plans must have policies in place to resolve grievances quickly and efficiently, according to CMS guidance. In fact, when an enrollee files a grievance against a provider, the plan must respond within 30 days.

Reminder: Grievances are not the same as initial determination and appeal procedures, CMS says. “Any communication from an enrollee must be reviewed on a case-by-case basis to determine how it should be categorized. The enrollee is not required to use any specific language to indicate what they are requesting.”

Additionally, “plans must determine whether the matter or the issue is a grievance, coverage request, appeal, or combination of more than one category and inform the enrollee (verbally or in writing) if the issue is a grievance or an appeal,” the agency notes. “If an enrollee raises two or more issues at the same time, then each issue should be processed separately and simultaneously (to the extent possible) under the appropriate procedure.”

MA plan staff must be able to “distinguish between coverage requests, appeals, and grievances,” CMS advises.

Find more information on the grievance process at www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Parts-C-and-D-Enrollee-Grievances-Organization-Coverage-Determinations-and-Appeals-Guidance.pdf.