A grievance in healthcare is a formal mechanism that allows patients to express dissatisfaction with the services, quality of care, or conduct they experience from a provider or health plan. This process ensures patients have a structured channel to voice concerns that go beyond minor, immediate complaints. It allows healthcare organizations to review and address failures in service delivery. Understanding this formal process is the first step toward advocating for better care and service.
Defining Formal Healthcare Grievances
A formal healthcare grievance is a documented expression of dissatisfaction with the operations, activities, or behavior of a health plan or its providers. This formal complaint usually relates to issues that cannot be resolved quickly by staff, requiring a structured investigation. This process is mandated by regulatory bodies, including the Centers for Medicare and Medicaid Services (CMS), for most healthcare providers and insurance plans.
The purpose of this formal system is two-fold: to provide internal review and ensure regulatory compliance. By documenting and tracking these complaints, organizations can identify systemic failures, leading to quality improvement across their services.
Grievances Versus Appeals: Understanding the Difference
The distinction between a grievance and an appeal centers on the subject of the complaint—whether it concerns the way care was delivered or whether the care is covered. A grievance focuses on the delivery of care and services, such as poor customer service, long appointment wait times, or disrespectful staff behavior. These issues relate to the patient’s experience and the quality of the interaction, not the financial or medical necessity of the treatment itself.
In contrast, an appeal is a formal request to reconsider a decision to deny payment or coverage for a specific service, drug, or medical procedure. For example, if a health plan refuses to pay for a particular surgery, the patient would file an appeal to challenge that denial based on medical necessity or contract terms. Appeals are about overturning a coverage determination, while grievances address the service aspect of the healthcare experience. Different forms, departments, and timelines apply to each process.
Common Issues That Qualify as a Grievance
A wide range of patient experiences can qualify as a formal grievance, especially when they involve a failure of service or a breach of patient rights. Issues related to the quality of service often include excessive waiting times for scheduled appointments or the inability to access necessary treatment in a timely manner. Poor coordination of care, such as a lack of communication between different departments or providers, also falls under this category.
Concerns about patient rights and staff conduct form another common group of grievances. This includes instances of disrespectful or rude behavior by nurses, doctors, or administrative staff, as well as alleged neglect or abuse. Furthermore, any failure to adhere to privacy regulations, such as a potential Health Insurance Portability and Accountability Act (HIPAA) violation, should be filed as a grievance.
The physical environment and safety of a facility can also prompt a formal complaint. These grievances might involve sanitation concerns, unsafe conditions within a hospital room, or any other issue that compromises the patient’s well-being.
Filing a Grievance: Steps and Timelines
Initiating a formal grievance requires identifying the correct entity responsible, such as the hospital, the provider’s office, or the health insurance plan. While some organizations allow verbal submissions for urgent issues, a written submission is strongly recommended to create a clear record. The submission should include specific details, such as the dates and times of the incident, the names of any staff involved, and a clear description of the events.
Most healthcare plans require that a formal grievance be filed no later than 60 calendar days after the incident that caused the dissatisfaction. The organization receiving the grievance is subject to a mandated timeline for investigation and resolution. For standard grievances, the entity must generally respond with a decision and a detailed explanation within 30 calendar days of receipt.
The written resolution provided to the patient must outline the steps taken to investigate the complaint and the results of that investigation. Potential outcomes may include corrective action taken against a staff member, a change in policy or procedure to prevent future occurrences, or a detailed explanation of why the entity found no fault.