How to file a complaint with CMS/JACHO/AAAHC and other Accreditation Organizations as well as the Department of Health Services (DHS)
What is the Center for Medicare & Medicaid Services (CMS)? It is an agency within the US Department of Health & Human Services responsible for administration of several key federal health care programs. In addition to Medicare (the federal health insurance program for seniors) and Medicaid (the federal needs-based program), CMS oversees the Children’s Health Insurance Program (CHIP), the Health Insurance Portability and Accountability Act (HIPAA) and the Clinical Laboratory Improvement Amendments (CLIA), among other services.
What is an accreditation organization? It is a system put in place for healthcare organizations to participate and demonstrate the ability to meet predetermined criteria and standards that are established by an accrediting agency. On site surveys are conducted by industry experts. A comprehensive review is conducted of the organizational structure, policies & procedures, compliance with federal/state/local laws, leadership, patients’ rights & responsibilities, fiscal operations, HR, provision of care, patient records, quality outcomes, performance improvement, infection control, and patient/employee safety. At the time of survey, the organization needs to demonstrate how they have maintained compliance with the accreditation organization.
The Centers for Medicare and Medicaid Services (CMS) has
required agencies to become accredited by an approved accreditor before they
can participate with Medicare.
Why is this important? Because Medicare sets-up the reimbursement rates for insurances as well as medical standards of practice. Therefore, filing a complaint with these agencies is vital, and key to be heard if your patient’s rights have been violated. A great example, are those Essure victims that went in thinking they were getting a tubal ligation and ended up with Essure. Or if you are having a hard time being heard by your doctor, etc.
Filing a complaint (grievance) with insurance
First, if you feel your provider did not provide you with quality of care, file a complaint (grievance) with your insurance. Regardless, if you have private or Medicaid, if you have concerns about your provider you can file a complaint.
Filing a complaint with CMS and accreditation organizations
You need to find out if your facility (hospital) or physician is accredited. You can do so by looking for any signs in the lobby, or on business card or simply asking the front desk staff. But normally there would be a visible seal of approval somewhere in the entrance area.
And if you want to double check you can look the information online. Example, this is JACHO’s link and you can put your hospital/doctor’s information. It will tell you if they are accredited/certified.
The following are links to where you can file a complaint to your hospital/physician’s accreditation company.
Centers for Medicare and Medicaid Services (CMS)
Filing a complaint with your local Department of Health Services
After you file a complaint with the accreditation you might want to consider a follow up complaint to your local Department of Health Services. This can trigger for surveyors to go out and investigate the problem.
International accreditation Joint Commission International