A Guide: How to Complain About Your Medical or Dental Care

Transcription

1 A Guide: How to Complain About Your Medical or Dental Care This packet will guide you through the processes of: * complaining to a hospital about a health care provider on staff; * filing a formal grievance against a health care provider; * making a complaint to a licensing board or medical association; * finding a medical malpractice lawyer. It will also help you understand how each process works and what happens after you make a complaint. The Natalie Lanam Justice Center Sobrato Center for Nonprofits 330 Twin Dolphin Drive, Suite 123 Redwood City, CA General: (650) (800) Fax: (650) /1/2012

2 Table of Contents Dear Health Consumer... 3 Option One: Complaining to a Hospital... 6 When can I complain to a hospital?... 6 How do I complain to a hospital?... 6 What happens when I complain to the hospital?... 7 Option Two: Filing a Grievance with Your Health Plan... 8 When may I file a grievance?... 8 How do I file a grievance?... 8 How can I contact the Department of Managed Health Care (DMHC)? Other resources Option Three: Filing a Complaint With a Licensing Board or a Medical Association What is a licensing board or medical association? What are the different licensing boards and how do I contact them? The licensing board for doctors, physician assistants, and affiliated healing arts professionals The licensing board for physician assistants The licensing board for podiatrists The licensing board for osteopaths The licensing board for registered nurses The licensing board for acupuncturists The licensing board for psychologists and psychological assistants The licensing board for dentists, registered dental hygienists, and registered dental assistants Physical Health Complaints What types of complaints does the Medical Board of California accept? How do I file a complaint with the Medical Board? How do I complain to a medical association about a problem with a doctor? Contacting a local medical association Mental Health Complaints What types of complaints does the California Board of Psychology accept? Are there any complaints the Board of Psychology will not accept? What happens if I file a complaint with the California Board of Psychology? Dental and Oral Health Complaints What types of complaints does the Board of Dental Examiners accept? When should I contact the California Dental Association (CDA)? How does the peer review system work? Are there any types of complaints the peer review system will not investigate? How do I file a complaint with a local dental association? Option Four: Filing a Medical Malpractice Suit What is malpractice? How do I file a malpractice suit? What will happen once I start a malpractice suit? /1/2012

3 Dear Health Consumer You are receiving this packet because you contacted the Legal Aid Society of San Mateo County with a complaint about your medical or dental care. This packet describes four options you have if you are unhappy with the care you received. You can: 1. Complain to the hospital where your doctor works; 2. File a grievance with your health insurance plan; 3. File a complaint with the organization that licenses doctors or dentists, or with the local medical association; OR 4. File a malpractice lawsuit. Note: You can choose more than one of these options. However, each one has deadlines and you should start as soon as possible. This packet does not advise you about the timelines for your specific case. 3 1/1/2012

4 This packet gives you practical advice and information, but not legal advice. If you are having a problem with your health insurance plan, you can make an appointment with a lawyer at the Legal Aid Society of San Mateo County s Health Consumer Center. The Health Consumer Center can help you appeal a denial of service or medication, and advise you about your rights. Keep in mind that Medicare and Medi- Cal have their own rules about what health insurance plans must cover. For any questions about these rules or about your health insurance plan, contact the Health Consumer Center. Legal Aid Society of San Mateo County Health Consumer Center Sobrato Center for Nonprofits 330 Twin Dolphin Drive, Suite 123 Redwood City, CA (650) (800) Fax: (650) Please note that this information is current for January 1, The law may have changed since then. 4 1/1/2012

5 This packet is divided into four sections: one for each complaint process. Included are some of the forms you need and information about where you can obtain other necessary forms. The packet also includes information to help you decide what actions are right for you. Whatever decision you make, do not hesitate to take control of your health. Make telephone calls. Ask for information. Keep notes. Write down the date you called and the name of the person with whom you spoke. Follow up in writing. Remember to be as clear as you can about what happened and what your complaint is. Also, you can always change doctors regardless of whether or not you decide to file a complaint. If you ask, your health plan s Member Services Department should help you pick a new doctor. REMEMBER: If you make a complaint, include as much specific information as you can. Names, addresses, and phone numbers of your doctors are important. Also include copies of any documents such as your medical records, bills or letters. Do not send the original documents. Keep the originals in case you need them later. Always keep copies of anything you write and mail. You may also need to sign a form allowing the people who investigate your complaint to get a copy of your medical records. 5 1/1/2012

6 Option One: Complaining to a Hospital When can I complain to a hospital? You can complain to a hospital if you think your doctor gave bad care or acted inappropriately. It does not matter if you received your care at that hospital or somewhere else so long as your doctor works at the hospital. Hospitals will look into complaints about any doctor who works with them. When a doctor works at a hospital, he or she is on staff there. How do I complain to a hospital? 1) If you did not see your doctor at a hospital, you must find out at which hospital your doctor works. You may have to ask the doctor s office. You can ask, What is the name of the hospital where my doctor is on staff? 2) Call the hospital and tell them you have a complaint about a doctor on the medical staff. Ask for the address where you should send your complaint letter. 3) Write a letter explaining your complaint. Be as clear as possible. Include dates, and notes from conversations. Describe the type of treatment you received from your doctor. Also, include the names of any other doctors who treated you or to whom you talked about your problem. Explain exactly why you think the care you received was poor quality. Keep a copy of everything you mail. 6 1/1/2012

7 4) After you have mailed your complaint, do not be afraid to follow up. Call to make sure the hospital received your complaint and ask what the next steps will be. What happens when I complain to the hospital? The hospital will review your complaint. Usually, a group of doctors from the hospital will read and discuss your complaint. They will also look at your medical records and may talk to your doctor. The action they take depends on how serious they think your complaint is. They may punish the doctor. They may make him or her stop working at that hospital. Or they may refer your case to the Medical Board. The hospital cannot give you money and they cannot take away your doctor s license. Even though this option is less formal than the other three, hospitals are often the most likely to read and look in to your complaint. Grievances with a hospital must be reviewed, investigated and resolved within a reasonable amount of time. This is usually about 7 days. The hospital should provide you with an easy to understand, non-technical written response that explains the hospital s decision. If you are unhappy with the hospital s decision, you may want to move on to one of the next steps. 7 1/1/2012

8 Option Two: Filing a Grievance with Your Health Plan Note: This packet only talks about what to do if you are unhappy with a decision your doctor made. If you are unhappy with a decision your health insurance plan made, you can contact Legal Aid s Health Consumer Center for help. When may I file a grievance? You may file a grievance when: Your doctor denies or unnecessarily delays treatment that you think you need. Your doctor provides poor medical care. Your doctor treats you rudely or violates your confidentiality. Your doctor is billing you for services covered by your health insurance plan. Any other situation where you think your doctor is violating the rules of your health insurance plan. How do I file a grievance? To file a grievance with your health insurance plan: 1) Call the Member Services Department of your health plan. To see a list of all health plans in California, go to: 2) Ask for the forms you need to file a grievance. 3) Complete the forms, keep a copy for your records, and mail the originals to your health plan. 8 1/1/2012

9 Within 30 days, your health plan is required to tell you what actions they are taking in response to your grievance. During this 30 day period, the health plan will investigate your complaint, and may talk to your doctor and contact you for more information about your complaint. If your health plan takes more than 30 days to resolve your grievance, or if you are not happy with your health plan s final decision in the grievance process, you can appeal that decision. An appeal can be filed with the California Department of Managed Health Care (DMHC) within 6 months of the final decision. The complaint forms for the DMHC are at the end of this packet. Are you a member of Health Plan of San Mateo? If you are a member of Health Plan of San Mateo, then you can file a grievance with Health Plan. There are several ways for you to file a complaint with Health Plan of San Mateo. 1) You can complete the online form, available at: 2) You can call Member Services at (650) , or the Grievance and Appeals Coordinator at (650) ; 3) You can fax your complaint to (650) ; or 4) You can mail a written complaint to: Health Plan of San Mateo 701 Gateway Blvd., Suite 400 South San Francisco, CA Attention: Grievance and Appeals Coordinator 9 1/1/2012

10 A brochure explaining the complaint process for Health Plan of San Mateo will be at the end of this booklet. For more information and for legal advice about filing a grievance against your health insurance plan, contact the Health Consumer Center. How can I contact the Department of Managed Health Care (DMHC)? Other resources Department of Managed Health Care (DMHC) California Help Center 980 Ninth Street, Ste. 500 Sacramento, CA Phone: (888) HMO-2219 Fax: (916) TDD: (877) Website: The California Patient s Guide gives a detailed explanation of your health care rights and the grievance process. It includes sample letters and forms. To get a free copy, call HMO-2219 (California Department of Managed Health Care). The guide is also available on the Internet at: /1/2012

11 Option Three: Filing a Complaint With a Licensing Board or a Medical Association What is a licensing board or medical association? The licensing board is the organization that gives your health care provider the license to practice. A medical association is an organization that represents specific groups of health care providers (such as doctors or dentists). Some associations are for specialists (for example, pediatricians). There are local, statewide, and national medical associations. Medical associations and licensing boards both accept complaints. Medical associations accept complaints against their members. Licensing boards accept complaints against any health care provider they license. If you are unhappy with the care you received, medical associations or the appropriate licensing board will investigate your complaint. Depending on their findings, they may take action to punish your doctor or dentist. The type of punishment your doctor or dentist receives depends on what happened. However, the associations and licensing boards never award money to patients. If your complaint is very serious, you may want to contact the licensing board. Only the licensing board can administer the most serious punishment: it can take away a health care provider s license. If your complaint is less serious, you can contact one of the medical associations. You can contact either the statewide or local association. If a 11 1/1/2012

12 medical association thinks your complaint deserves a more serious punishment than they can give, they will refer the complaint to the California State Attorney General s office or to the appropriate licensing board. What are the different licensing boards and how do I contact them? The licensing board for doctors, physician assistants, and affiliated healing arts professionals Medical Board of California Central Complaint Unit 2005 Evergreen St., Suite 1200 Sacramento, CA Phone: (800) Or (916) TDD: (916) Fax: (916) Website: The Medical Board of California accepts complaints about: Doctors; Dispensing opticians, spectacle lens dispensers, and contact lens dispensers; Licensed midwives; and Research psychoanalysts. 12 1/1/2012

13 The Board also investigates complaints about licensees in the following professions; however, the disciplinary action is taken by the respective licensing entity. Physician Assistants: contact the Physician Assistant Committee of the Medical Board of California. Doctors of Podiatric Medicine: contact the Board of Podiatric Medicine. Osteopaths: contact the Osteopathic Medical Board of California. Psychologists and Psychological Assistants: contact the Board of Psychology. (See section on Mental Health, beginning at page 20 of this packet.) The licensing board for physician assistants Physician Assistant Committee Medical Board of California 2005 Evergreen St., suite 1100 Sacramento, CA Phone: (916) Fax: (916) Website: /1/2012

14 The licensing board for podiatrists Board of Podiatric Medicine 2005 Evergreen St., Suite 1300 Sacramento, CA Phone: (916) Fax: (916) Website: Complaint Info: mplaints The licensing board for osteopaths Osteopathic Medical Board of California 1300 National Drive, Suite 150 Sacramento, CA Phone: (916) Fax: (916) Website: Complaint Info: complaints.shtml The licensing board for registered nurses Board of Registered Nursing 1625 North Market Blvd., Suite N217 Sacramento, CA Mailing Address: P.O. Box Sacramento, CA /1/2012

15 Phone: (916) TDD: (916) Fax: (916) Website: Complaints Info: s/complain_rn.shtml The licensing board for acupuncturists Acupuncture Board 1747 N. Market Blvd, Suite 180 Sacramento, CA Phone: (916) Fax: (916) Website: Complaint Info: mer_comp.shtml The licensing board for psychologists and psychological assistants Board of Psychology 2005 Evergreen St., Suite 1400 Sacramento, CA Phone: (916) For Complaints: (866) Website: Complaint Info: complaints.shtml 15 1/1/2012

16 The licensing board for dentists, registered dental hygienists, and registered dental assistants Dental Board of California 2005 Evergreen St., Suite 1550 Sacramento, CA Phone: (916) Or (877) Fax: (916) Website: Complaint Info: info.shtml Physical Health Complaints If you have a complaint about a physical health care provider, you can contact the Medical Board of California or other licensing board, the California Medical Association, or your local medical association. See pages to find the appropriate licensing board. What types of complaints does the Medical Board of California accept? The Medical Board of California will investigate any complaint made against a health care provider it licenses, unless the issue relates to Medi- Cal or Medicare. The Medical Board investigates complaints about: the quality of care and treatment provided by your doctor; substance abuse by a doctor (for example, drug and alcohol use); sexual misconduct; dishonesty; 16 1/1/2012

17 the unlicensed practice of medicine; and other improper behavior. How do I file a complaint with the Medical Board? You can call the Board s Central Complaint Unit with any questions. Questions can be about whether to file a complaint, or how to file a complaint. See page 12 for contact information. Your complaint must be against a specific health care provider. To file a complaint with the California Medical Board: 1) Fill out the forms at the end of this packet. Make a copy for your records. Mail the originals to the Medical Board. 2) After investigating your complaint, the staff of the Medical Board will take the appropriate actions. Quality of care issues will be reviewed by a medical expert. If there is a legal issue supported by the investigation which supports discipline, then the Attorney General will be contacted for administrative action. If there is not enough evidence that a violation has occurred following the investigation, then the case will be closed. 3) You will receive a letter of correspondence with a control number for your complaint. To check on the status of your complaint, call the Medical Board with your control number. 17 1/1/2012

18 Note: See pages 12 and 13 for the list of health care providers that the Medical Board licenses, and the actions it may take. How do I complain to a medical association about a problem with a doctor? If your doctor is a member of the California Medical Association (CMA), you can contact your local CMA chapter for help. The California Medical Association is an organization that represents and advocates for more than 30,000 California doctors. It has local chapters throughout California. The main office does not handle complaints, but you can ask them for the address and phone number of a local chapter. The Legal Center of the CMA also keeps this information. California Medical Association (CMA) Phone: (800) Fax: (916) After you contact the local chapter, a mediation committee will be assigned to your case. This committee will look at any situation where your doctor gave bad medical care or behaved unethically. The local chapter will then try to resolve your complaint. Any doctor who is a member of the CMA is required to go through this process if you request it. The CMA cannot 18 1/1/2012

19 make your doctor give you money. The CMA cannot take away your doctor s license. However, the local chapter will investigate the situation for you and will review it with the help of other doctors. If the CMA thinks the problem is extremely serious, it can refer the problem to the Medical Board (the licensing board) or the State Attorney General. Contacting a local medical association You must contact the medical association of the county in which your doctor practices. Some doctors practice in more than one county but have one main office. You can call the CMA to find out if and where the doctor is a member of a local association. For San Mateo County, contact: San Mateo County Medical Association 777 Mariners Island Blvd., Suite 100 San Mateo, CA Voice: (650) Fax: (650) smcma@smcma.org Website: For Santa Clara County, contact: Santa Clara County Medical Association 700 Empey Way San Jose, CA Voice: (408) Fax: (408) Website: /1/2012

20 For San Francisco County, contact: San Francisco Medical Society 1003-A O Reilly Avenue San Francisco, CA Voice: (415) Fax: (415) Website: Mental Health Complaints You may contact the California Board of Psychology (see page 15 for address and contact information) if you have a complaint about a psychologist or psychologist s assistant. You do not have to contact the Medical Board first. A complaint form is at the end of this packet. Note: psychiatrists are medical doctors (MDs) and are licensed by the Medical Board of California. What types of complaints does the California Board of Psychology accept? The California Board of Psychology punishes illegal, irresponsible, or unprofessional behavior. Types of behavior that fit this description are: Providing services without the proper training or license; Violating the patient s confidentiality agreement (telling people about a patient s case without the patient s consent); Sexual contact with a patient; 20 1/1/2012

21 Drug or alcohol abuse; False advertising, fraud, or other crimes; Paying or accepting payment for referrals; Focusing therapy on the mental health professional s own problems instead of the patient s; Having interactions with the patient besides providing mental health care; Any other unprofessional, unethical or irresponsible acts. Are there any complaints the Board of Psychology will not accept? Yes, the Board has no authority over: Fee or billing disputes; General business practices; Personality conflicts; Persons who are licensed by other boards (for example, clinical social workers; marriage, family, and child counselors; educational psychologists; psychiatrists; or psychiatric technicians). What happens if I file a complaint with the California Board of Psychology? The Board will tell you it has received your complaint within 10 days of its receipt. If your complaint involves a minor violation, it may be handled in one of several ways. The Board may: 1. Work to reach an agreement between you and the psychologist or psychologist s assistant. assistant. 2. Send a warning letter to the psychologist or psychologist s OR 21 1/1/2012

22 3. Set up an educational conference for psychologist or psychologist s assistant. If your complaint involves a more serious violation, such as sexual abuse, serious lack of responsibility, or incompetence, the California Board of Psychology will send your case to the Medical Board. You will be told if this happens. At this point: 1. A trained person from the Medical Board will investigate your complaint. 2. The investigator assigned to your case will interview you. During the interview, you will be able to discuss the details of your complaint and ask questions about the process. 3. The investigator will also interview the psychologist. Details of your complaint and the investigation are confidential. But your psychologist or psychologist s assistant will be told about your complaint, and given an opportunity to respond. Dental and Oral Health Complaints If you have a complaint about a dentist, registered dental hygienist, or registered dental assistant, you can contact the Board of Dental Examiners, the California Dental Association, or your local dental association. 22 1/1/2012

23 What types of complaints does the Board of Dental Examiners accept? The Board of Dental Examiners punishes dentists, dental hygienists, and dental assistants who act unprofessionally, are not qualified, or make significant or repeated mistakes, for example: Charging a fee for services the dentist did not perform; Crimes relating to dentistry, including drug or alcohol use, breaking laws about prescribing medications, and giving out dangerous drugs or narcotics; Giving or helping someone else give unlicensed dental care, or practicing under a false name; False advertisement including advertising professional superiority; Improperly changing patients records; Unsafe or unsanitary office conditions; Abandoning patients or other improper conduct. If you want the Board of Dental Examiners (Dental Board) to investigate your complaint, you must complain in writing. Contact information is on page 16 of this packet. When should I contact the California Dental Association (CDA)? The California Dental Association (CDA) investigates complaints about the quality of dental care. It also looks at unethical behavior. The CDA uses a system, free of charge, called peer review. A peer review committee is a group of volunteer dentists. If you file a complaint, the peer review committee will investigate what happened. Then, the committee will decide how it thinks your complaint should be resolved. If you disagree, or you 23 1/1/2012

24 think the peer review process did not consider all the facts, you can ask for an appeal. Your dentist can also appeal. Appeals are made to the Council of Peer Review. The appeal request must be made within 30 days of the letter telling you what the peer review committee decided. The decision of the Council s appeals panel is final. California Dental Association 1201 K Street Sacramento, CA Phone: (800) contactcda@cda.ca.gov Website: How does the peer review system work? All disputes and complaints that are evaluated within the peer review system must follow the following guidelines and procedures: The local chapter of the CDA administers the peer review. You must sign a Patient Agreement Form. This says that you will accept the decision of the dental association. Members of the California Dental Association have already agreed to this. You must also sign an Authorization for Use and Disclosure of Health Information Form. This allows the committee to legally get your dental records for the investigation. A panel of at least three dentists will examine you, unless the treatment you received cannot be evaluated. (For example, if you already corrected any problems with the treatment.) The dentist can choose to talk to the peer review committee. The committee will contact all other involved parties for information. For example, they may call your insurance and other dentists who treated you. 24 1/1/2012

25 The peer review committee will evaluate all available evidence, for example: your dental records, x-rays, or statements from other treating dentists. You will receive a letter of resolution, telling you what the committee decided, and why. Your dentist will also get a copy. You will receive information about appealing when you receive the final decision. Are there any types of complaints the peer review system will not investigate? years ago; The peer review system does not investigate complaints if: 1) Your complaint involves something that happened more than three 2) You already filed a lawsuit; 3) You are asking your dentist to pay you for time lost from work, pain and suffering, mileage, or other medical expenses; 4) Your complaint is about your dentist s fees (but you can complain if you are being charged for a treatment your dentist never completed); 5) Your complaint is unrelated to treatment (for example, if it is about your dentist s attitude). How do I file a complaint with a local dental association? The local dental associations are part of the statewide peer review system described above. Contact the association in the county where your dentist practices. 25 1/1/2012

26 counties: Contact information for San Mateo, Santa Clara, and San Francisco San Mateo County Dental Society 240A Twin Dolphin Drive Redwood City, CA Voice: (650) Fax: (650) Website: Santa Clara County Dental Society 1485 Park Ave. San Jose, CA Voice: (408) Fax: (408) Website: San Francisco County Dental Society 2143 Lombard Street San Francisco, CA Voice: (415) Fax: (415) Website: /1/2012

27 Option Four: Filing a Medical Malpractice Suit What is malpractice? Malpractice means medical mistakes or bad quality medical treatment. This includes treatment that makes your health problem worse instead of better, and treatment that causes new health problems. It also includes failure to treat. If you think your doctor, psychologist, or dentist committed malpractice, you may choose to sue in a court of law. Examples of malpractice: The doctor or dentist is slow to or fails to diagnose a disease or condition. A problem happens during an operation. The doctor or dentist does an operation without the informed consent of the patient. That means the doctor or dentist did not make sure the patient understood all the risks of the treatment and what the alternatives were before the operation. After making the right diagnosis, the doctor or dentist treats the health problem incorrectly. The doctor or dentist prescribes the wrong medication and this leads to more health problems. How do I file a malpractice suit? If you think you have a medical malpractice claim, you should contact a lawyer immediately. You only have a limited time to file your lawsuit. The Lawyer Referral Service of San Mateo County will arrange a half hour meeting with a lawyer for you. There is a small fee for this meeting ($30 at the time this packet was written). If the cost is a problem for you, you 27 1/1/2012

28 should mention this when you call, as you may be able to qualify for the Modest Means program based on your income. You can call the Lawyer Referral Service at (650) However, you should know that malpractice complaints take a long time to resolve, are complicated, and are often difficult to prove. Lawyer Referral Service of San Mateo County 333 Bradford Street, Suite 200 Redwood City, CA Phone: (650) Website: The San Francisco Lawyer Referral Service occasionally serves clients outside of San Francisco County. You can call San Francisco Lawyer Referral Service at (415) You will speak with an interviewer and be asked to describe your case while the interviewer does a brief intake with you over the phone. Your case will then be reviewed by a staff attorney who decides whether or not to schedule a consultation for your case. You will be contacted within two to three business days if the attorney agrees to give you a consultation for your case. You will then be able to meet with the attorney for an initial 30 minute consultation. The initial meeting costs $35 and there is no fee waiver for low-income individuals. For injury matters, there is no fee to consult a lawyer. 28 1/1/2012

29 San Francisco Lawyer Referral and Information Service 301 Battery St., Third Floor San Francisco, CA Phone: (415) TDD: (415) Website: Online Case Submissions: onlinereferral.aspx What will happen once I start a malpractice suit? After your first consultation with a lawyer, he or she does not have to take your case. Make sure you understand if the lawyer is agreeing to represent you. It is the lawyer s responsibility to determine quickly whether your case is strong enough to go forward. In addition: You must reach an agreement with the lawyer about how the lawyer will be paid. The lawyer may want you to pay him or her by the hour. Or, the lawyer may agree to advance all costs. In this case, he or she will only be reimbursed and paid if you win and get money awarded to you. This is called a contingent fee. This contingent fee is set by law. In a contingent-fee case, if you do not win your case, you do not pay the lawyer. Make sure you understand what your fee agreement says. At the first meeting, the lawyer will want to see a detailed medical history. You should make a list of all doctors or dentists who treated 29 1/1/2012

30 you. The lawyer will also want the names of all hospitals you have visited. It may help for you to prepare a written time line of all medical treatment you received. Include as many details as possible, such as: dates, doctors, symptoms, conversations with medical providers, and treatment received. Afterwards, the lawyer will want to see your medical records. The lawyer will probably not be able to tell you if you have a good case before reviewing your medical records. If you do go forward with a malpractice lawsuit, it may take years before it is resolved. 30 1/1/2012