Employees in complex bureaucracies are also victims of the system they administer. So when organizational gatekeepers are invoking bureaucratic rules that prevent you from obtaining care, you may need to needle them with the bureaucratic structures governing them. In short, you complain to someone else in the organizational structure so that the pressure on the person or department you want to move to action comes from someone other than you.
The first step, as in any legal maneuver, is to establish an achievable goal. If you are seeking to talk to a doctor or obtain a certain treatment, be clear about what it is you want. Sometimes the bureaucracy can be so annoying that you want to inflict the kind of pain on the people within it that the system has inflicted on you. This is not an achievable legal goal. Working in a large bureaucracy is its own punishment and the people who work there already know that. Figure out exactly what you want, stick to it, and stop when you get it.
The next step is to use the grievance procedure established by the bureaucracy itself.
Most of the Americans who read this elder law blog receive Medicare. Providers who accept Medicare are governed by many of rules. One of those rules requires the hospitals to have a grievance procedure. That procedure must include the following:
- A contact person to receive a grievance
- A grievance committee to resolve grievances
- A clear procedure for submitting a grievance
- Set time frames for review of a grievance
- Written notice of the decision that contains the name of a contact person, the steps taken to investigate the grievance, the results of the process, and the date of completion.
Every medical provider that accepts Medicare must satisfy this rule.
My Medicare Advantage policy at Kaiser states:
As a plan member, you have the right to get appointments and covered services from our network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays.
If I am denied timely service due to an overly complex and incomprehensible scheduling system, I am being denied timely services. My complaint would be that I am being denied timely services for whatever condition I can't seem to have addressed. Kaiser accepts complaints by phone, online or in writing. I would suggest writing. Bureaucracies love writing. Kaiser sends me so much mail, I have to assume that it prefers mail. The address is:
Kaiser Foundation Health Plan of the Northwest
500 NE Multnomah St, Suite 100
Portland, Oregon 67232-2099
Kaiser's internal rules require that they must respond in thirty days (but they can get an extension of another fourteen days.) This is the process to use if you feel that you are being denied, through undue bureaucratic hurdles, care for conditions that are clearly covered. If the dispute is about whether your policy covers a certain treatment, the process is different and far more complex. I suggest wording the complaint in a form that suggests you are being denied timely care due to bureaucratic delay.
Providence Hospital has a long statement of rights, which includes "The right to voice complaints about the care, and to have those complaints reviewed and when possible, resolved." The website further states that "a formal grievance may be filed at the hospital’s quality management department office."
Adventist Hospital take complaints ("grievances" if you like the legaleze) at
Adventist Health Compliance Hotline
2100 Douglas Blvd.
Roseville, CA 95661
It is unrealistic for me to give the contact information for each hospital, but the idea is the same. The hospital takes Medicare, thus it has to have a formal grievance procedure. Begin by using it. This sets in motion mandatory bureaucratic processes that take up time and energy. With a little luck someone will determine that giving you what you want is less work than doing all the procedural steps necessary to fully comply with the Medicare grievance procedures.
If this does not work, it may be time to make your complaint to outside agencies. My next post will provide a framework for how to do that.