What should you do when your office receives a grievance letter?
First and foremost, verify who is asking for the written response. If you have received an inquiry letter from the Medical Board of California (MBC), that is different than a health plan grievance. An MBC letter should be referred immediately to the CAP Cares Hotline at 800-252-0555.
Grievances or complaints could originate directly from patients, or from the patient's healthcare plan. Healthcare plans are required to have a grievance program and the rules require they respond to grievances within specified timeframes. The grievance process was written and designed to address genuine patient safety concerns of plan members. The nature of the grievance can range from perceived injustices to unequivocal errors:
- "I received poor care."
- "I was treated rudely."
- "I had to wait too long for an appointment."
- "I received an injection intended for another patient."
Perhaps the patient may have misinterpreted the clinical situation or misunderstood the follow-up plan. Regardless of the specifics of the case, this is not a situation that can be ignored, nor should the response be delegated. (If the grievance involves an unexpected outcome or an “adverse event,” you should contact CAP Cares at 800-252-0555.) Vet each for what “category” a complaint or grievance resides.
The order of events concerning response to grievance is generic:
- Member (patient) complains to his/ her carrier about their experience.
- Healthcare plan notifies you about the grievance and seeks a response.
- You respond to the healthcare plan.
- The 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 who responds to the plan, which responds to the patient.
Complaints that come from the patient follow a similar format, except you are dealing directly with the patient vs. a more objective personality within the healthcare plan. Again, the response is tailored to the complaint and clinical conditions. Most complaints are managed via “customer service” gestures – we just call our customers “patients”.
This brings us to your response. You must be sure to craft a professional, respectful, comprehensive, and objective written response to the grievance. The physician, not the medical assistant, should draft the response to confirm the accuracy of the clinical facts. Your response could include:
- A brief, responsive opening line
Chronology of the medically relevant care given, including:
- date(s) the patient was seen
- purpose of visit(s)
- physical exam findings
- medical impression
Recommended treatment plan, including:
- labs, tests, etc.
- return visit instructions
Close by including your telephone number for any questions. Click here to download a sample Grievance Response Letter.
Lee McMullin, CPHRM
Senior Risk Management & Patient Safety Specialist
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.