Distinguishing Between Member Appeals and Member Grievances
Complaints are considered any expression of dissatisfaction to a Medicare health plan, provider, facility or Quality Improvement Organization (QIO) by an enrollee made orally or in writing. There are two procedures for resolving MA member complaints: the Medicare member appeals process and Medicare member grievance process. All member concerns are resolved through one of these mechanisms. The member’s specific concern dictates which process is used. Thus, it is important for the physician to be aware of the difference between appeals and grievances.