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The information on this website is not intended as legal advice or a comprehensive analysis of healthcare regulation. Healthcare providers, patients, and advocates should seek advice from legal counsel to be certain of the laws, rules and requirements of their particular state or jurisdiction.

Why should providers care about patient complaints?

Resolving patient complaints is mission critical to improving patient experience and achieving long-term business success. Here are five reasons providers should care about resolving patient complaints:

  • Unhappy patients take their business elsewhere.
  • Patients’ opinions about their healthcare affect other patients’ choice of provider.
  • Patient experience survey results affect provider reimbursement.
  • Patient complaints contain valuable information about quality improvement opportunities.
  • Federal regulations mandate that most Medicare-certified healthcare providers investigate, resolve and follow up on patient complaints and grievances.

What are the regulations governing a patient complaint and grievance process?

Healthcare providers should reference the patient grievance regulations specific to their provider type. CMS requires most certified health care providers to establish a process to investigate and respond to patient complaints and grievances in a timely manner.

Patient Grievance Regulations by Provider Type
Provider Type Regulation
Ambulatory Surgical Center 42 CFR §416.50(d)
End Stage Renal Disease 42 CFR §494.90
Home Health Agency 42 CFR §484.50(e)
Hospital 42 CFR §482.13(a)
Long Term Care Facility 42 CFR §483.10(f)

What are the steps to implementing a patient complaint and grievance process?

  1. (Hospitals only) Ensure hospital’s governing body takes responsibility for the grievance process;Establish policies and procedures for prompt resolution of patient grievances;
  2. Educate patients about their rights, including the grievance process;
  3. Educate employees about the grievance process;
  4. Investigate patient grievances;
  5. Resolve patient grievances;
  6. Document compliance with patient grievance requirements; and
  7. Incorporate grievance data into the hospital quality improvement process.

What are some things to consider when implementing a service recovery program?

In an effort to resolve patients’ minor complaints, providers sometimes give patients service recovery gifts or waive copayments and/or deductible amounts. Providers must be aware that there are legal restrictions on the value of service recovery gifts and waivers of copayments and deductibles. Providers should consult their compliance officer or legal counsel to ensure compliance with the Anti-Kickback Statute (AKS) and related state laws.

When writing a Service Recovery Policy consider:

  • Identifying the purpose of the service recovery policy.
  • Defining service recovery gifts.
  • Specifying:
    • An individual service recovery gift will not have a value exceeding $10.
    • Service recovery gifts may not have an aggregate value in excess of $50 per patient per year.
    • Gift cards will only be redeemable at specific vendors that do not sell items or services paid for by Federal health care programs (such as pharmacies or durable medical equipment suppliers).
    • Gift cards may not be redeemable for cash or for items or services given by the provider.
    • The gift card program will not be advertised.
  • Implementing a system for tracking the issuance of the service recovery gifts to ensure that individual beneficiaries do not exceed the limit.
  • Requiring that service recovery gifts be secured and audited to prevent loss and/or theft.
  • Incorporating tracking and trending of service recovery gifts to enable managers to know when, where, and how often service shortfalls lead to the issuance of gift cards, thus allowing managers to address the underlying cause of the shortfalls.
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