full image - Repost: Tips on Writing an Effective Grievance (Grievance is complaint in KP lingo) (from Reddit.com, Tips on Writing an Effective Grievance (Grievance is complaint in KP lingo))
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Tips on Writing an Effective GrievanceI wanted to provide some tips about submitting grievances to KP, what has helped me and what to do if KP does not respond or provides an inadequate response. Hopefully this will help you get resolution to your issue. (I am in Southern California but tried to make this general so it applies to all regions.)Grievances have to be responded to by the designated department head / chief. Also, KP monitors grievances by department. There will likely be additional explaining a department head has to do if they start having an increasing number of grievances.If you have a complaint against a physician, physician assistant, nurse practitioner or nurse, file a complaint with the appropriate State Licensing board for that individual in addition to filing a grievance with Kaiser. Include the Kaiser grievance reference number in the complaint to the State Board.If you think the issue you’re reporting needs urgent attention, call the Expedited Review department through Member Services for your area. (I have done this and they really do follow up quickly.) Read through these tips and write up your grievance before you call. When you have them document the Grievance, have them read back what they have documented. (Make sure it is exactly how you want it and they did not editorialize or mischaracterize your complaint.) Ask for the Kaiser case reference number before ending the call.For NON-Urgent issues, submitting on-line is the easiest and best way using this form (for all regions). They have 30 days to respond to non-urgent grievances: https://ift.tt/MrJeIAj can also submit a paper copy of the grievance form: https://ift.tt/u6yFO2f the grievance against the appropriate department. (Example: If your doctor orders an MRI and you cannot get anyone in Radiology Scheduling to answer, file the grievance against Radiology Scheduling NOT your doctor.)Clearly explain the issue and why it is a problem. Don't get emotional.Include dates / times / names / titles / departments for physicians and staff who were involved, who you spoke with or were witnesses to the incident, as appropriate. If someone told you “We are backed up, that is why we can’t get you in for XXX months” or “The best thing for you to do is pay out of pocket and go out of network” include those quotes as well, who told you that and when.Cite references to published Kaiser policies or documents you were provided if there is an inconsistency between what you were told or what happened with your care and the published document.If they are relevant to the complaint, include messages sent to your physician in the complaint. Photos or other documentation can also be sent in to Member Services as additional supporting documentation. Once you get the initial letter that your grievance has been assigned a case manager, they will have their contact number in the letter and let you know how you can submit additional information.If you have tried to resolve the issue, include what you did to try and resolve it. (Example: "I sent a message to Dr. Jane Smith in the KP Patient Portal regarding the inaccurate documentation in my medical record on MM/DD/YY. I requested the Progress Notes be amended to include XYZ.. As of MM/DD/YY, no response has been received.")Before you submit it, have a family member or friend review it to make sure your complaint is clearly stated, it is factual and not emotional and the facts are easy for someone not familiar with your situation to understand.Save copies of everything you submitted and everything you receive back from Kaiser. Documentation is key: even save fax confirmations and USPS delivery confirmations in case KP says "we never got that".If KP does not respond or you are dissatisfied, escalate it to the appropriate agency (for your region or state) listed in the Grievance response letter. Include everything you submitted and everything you received back. Include any additional dates / times / names/ titles of who you spoke to try and get resolution with the grievance.What to do if you cannot reach your assigned Kaiser Grievance Case ManagerIf you try and contact your Grievance Case Manager and cannot contact them (full voicemail, voicemail box not accepting messages) or leave messages, send faxes or send registered US Mail and they do not respond, document a complaint with the appropriate state regulatory agency for your area. Include all of your documentation as well as a timeline of when / who / how you tried to contact them and outcome (Examples: left voicemail message on 11/21/22 for Mary Smith, Case Manager, no return call; Tried to call Mary Smith, Case Manager, on 12/14/22—voicemail full and not accepting messages, etc.)How to Escalate if your Kaiser Grievance is Unresolved or You Are Not Satisfied with the ResolutionRemember that if your complaint is regarding a specific physician or other healthcare provider (nurse/nurse practitioner, physician assistant), file the complaint with the appropriate state licensing board for that provider. File the Kaiser grievance first and include the case reference number in your report to the licensing board.If your complaint is regarding a hospital (cleanliness, patient safety concerns, etc.), file a complaint with the Joint Commissionhttps://https://ift.tt/YC64fZ9 you have filed a grievance with Kaiser and it has gone unresolved or you are not satisfied with the resolution, here is a list of agencies you can document a complaint with (based on your state of residence). Include all documentation you sent to Kaiser and what they sent back.CaliforniaDepartment of Managed Health Care (DMHC)https://ift.tt/IGCVSbB In California, if you are having a difficult time obtaining a Mental Health Appointment (no appointments available, appointments keep getting cancelled, etc.), you can call DMHC during normal business hours and select Option 8 in their phone menu.OregonOregon Division of Financial Regulationhttps://dfr.oregon.gov/help/complaints-licenses/Pages/file-complaint.aspx1-888-877-4894Washington StateOffice of the Insurance Commissionerhttps://https://ift.tt/z8JKbUO of Regulatory Agencies, Division of Insurancehttps://doi.colorado.gov/for-consumers/file-a-complaint1-303-894-7490 / 1-800-930-3745GeorgiaOffice of Commissioner of Insurance and Safety Firehttps://oci.georgia.gov/file-consumer-insurance-complaint1(800) 656-2298HawaiiDepartment of Commerce and Consumer Affairshttps://cca.hawaii.gov/ins/consumers/filing_a_complaint/(808) 586-2790MarylandIf it is a healthcare quality complaint, Maryland Office of Healthcare Qualityhttps://app.smartsheet.com/b/publish?EQBCT=07c94438f6714af1bbfe8ff1037b8b741-410-402-8015If it is a billing, claims, medical records or coverage issue contact Maryland Attorney General, Health Education and Advocacy Unithttps://https://ift.tt/yg3CdFx of ColumbiaD.C. Department of Insurance, Securities and Banking (DISB)https://ift.tt/HtI1Qf8 727-8000VirginiaState Corporation Commission, Bureau of Insurance, Office of the Managed Care Ombudsmanhttps://scc.virginia.gov/pages/Office-of-the-Managed-Care-Ombudsman1-877-310-6560, select option 1
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