Patients come in many shapes and sizes, and so do their complaints, from the ridiculous to the serious. We frequently hear about these on the CAP Hotline, so we’re doing a short story on the subject.
For our purposes, we’ll call complaints as those coming directly from patients in either written or oral form. Grievances, on the other hand, are those from the patient’s healthcare plan, which all have a grievance management program. The grievance process is designed to address genuine patient safety concerns of plan enrollees.
To simplify, healthcare plans are required to have a grievance program and the rules require that they respond to grievances within specified times. The pathway is pretty simple:
- Member (patient) complains to his or her carrier about the doctor and/or experience
- Healthcare plan notifies you about the grievance
-
You respond to the healthcare plan
Plan responds to the member. - If the healthcare plan contracts with an intermediary, such as an IPA, then the plan notifies the IPA
- Which notifies you.
- Your response goes to the IPA
- Then to the plan
- And finally, to the patient.
This brings us to the response. In order for the plan to respond to its member, it needs to have your side of the story and within the allotted time to comply with the rules. Hence, the letter from the plan (or intermediary) has a timeline in which they need you to respond. The typical grievance letter cites the nature of the member/patient complaint and then seeks your responsive comments.
Grievances, as we said, come in all shapes and sizes – and may include:
- “I received poor care.”
- “I was treated rudely.”
- “I had to wait too long for an appointment.”
- “They won’t let me bring my therapy rat to the office.“
Your first step is to note the time you have to respond. If you need more time – contact the person identified as the coordinator at the health plan for more. Secondly, analyze if the complaint is legitimate or not. The patient may be correct, have misinterpreted the clinical situation, or be flat-out wrong. Your response should be objective and supported by facts. Include supportive record entries, documents, research, or articles as needed. Since this is a quality assurance process, HIPAA allows you to disclose PHI in your response. Consider the following format recognizing that a grievance requires a tailored response so these suggestions are not all-inclusive:
- A brief, responsive opening line
-
Chronology of the medically relevant care that, if indicated, includes:
- date(s) the patient was seen
- purpose of visit(s)
- physical exam findings
- medical impression
- treatment plan
- medications
- labs
- after-care instructions
Maintain a professional demeanor and respectful tone throughout the letter. Observe proper grammar and sentence structure. Close by offering to address any questions that may arise. It’s best for the physician to draft the response to confirm the accuracy of the clinical facts. This is not a subject to delegate to your MA or office staff.
If the grievance involves an unexpected outcome or “adverse event, “ we recommend you contact the CAP Cares Adverse Event Team before responding at 800-252-0555. If the complaint is via a letter from the Medical Board of California (MBC), it is different than a health plan grievance. An MBC letter should be referred immediately to CAP’s MedGuard program.
Lee McMullin is a Senior Risk Management and Patient Safety Specialist for CAP. Questions or comments related to this article should be directed to lmcmullin@CAPphysicians.com.