Your Guide to Filing a Complaint About HHS Programs and Services

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A woman called Livanta about her relative in a rehabilitation home. He was not getting enough physical therapy, she said, and his pain medication was not arriving on time. She wanted him moved somewhere else, and she wanted to speak to the social worker.

Livanta is the company Medicare pays to look into complaints about the quality of care. The coordinator offered her Immediate Advocacy, which means the reviewer makes the calls for you instead of opening a case. She said yes, her relative gave his own consent over the phone, and the coordinator phoned the home and spoke to the rehabilitation director. No form. No case number. A phone call.

Almost every complaint about a federal health program has an office that will take it. But the ones that change what happens to you are the fast appeals, not the complaints: a review on the day the hospital says you are going home, a decision from your plan due within hours. The offices with enforcement in their names mostly talk providers into fixing things, and most of the time they cannot give you anything at all.

A complaint and an appeal are two different machines

Medicare’s rules draw the line. A grievance is any complaint or dispute other than one that constitutes an organization determination, whether or not you ask for a remedy. An organization determination is the other thing: whether you are entitled to a service, and what you must pay.

That line decides your remedy. File a grievance and you get an answer. File an appeal and you can get the care.

Rudeness, a filthy room, a billing office that never calls back: grievance. Care refused, coverage ending, a bill you do not think you owe: appeal. Send the wrong one and the clock on the right one keeps running.

If your care ends tomorrow, do not file a complaint

You are in a hospital bed, and someone says you go home today. Ask for an expedited review by the Quality Improvement Organization, the outside reviewer Medicare contracts with in your area. The request must be made no later than the day of discharge, and it can be a phone call.

Leave first and you can still ask within 30 calendar days, or at any time for good cause. You just lose the protection against the bill.

Nursing homes, home health and hospice run on their own notice. The provider must tell you no later than 2 days before covered services end, or at admission if the stay will be shorter than that. Inside a Medicare Advantage plan, an expedited decision on a service is due no later than 72 hours after receiving the request. For a Part B drug the plan gets 24 hours, and that one cannot be extended.

None of these are complaints. They are appeals, and they are the only part of this system that moves at the speed of an illness.

Your plan is the first judge of your plan’s denial

The Department of Health and Human Services (HHS) Office of Inspector General sampled denials by Medicare Advantage plans and found 13 percent met Medicare coverage rules. Those services would likely have been approved under original Medicare.

One case from that report: a plan refused a walker (estimated cost $112) for a 76-year-old with post-polio syndrome. Its clinical criteria allowed one walking device every 5 years, and he had a cane. The inspector general’s coding expert found the Medicare coverage rule for walkers has no 5-year restriction in it.

Now the number worth remembering. Over 2014 to 2016, beneficiaries and providers appealed only 1 percent of denials to the first level. When they did appeal, plans overturned 75 percent of their own denials, roughly 216,000 reversals a year.

Three out of four reversed, and almost nobody asks.

Insurers say that reads the statistic backwards. AHIP, the health insurance industry’s trade association, argues the reports ignore why reversals happen: most often a provider’s office shares information that was missing from the initial claim, a paperwork gap rather than a wrong decision.

Both can be true, and for you they point the same way. If missing paperwork is what flips the answer, the appeal is how the paperwork gets sent.

Five levels, and a court that had to order the wait fixed

A denied original Medicare claim climbs a staircase: redetermination, reconsideration, an administrative law judge, the Medicare Appeals Council, federal court. The statute tells the judge to decide by not later than the end of the 90-day period.

It did not work out that way. The Office of Medicare Hearings and Appeals publishes its own averages: 1,430.1 days in FY20, then 137.0 in FY23 and 69.0 so far in FY26.

The deadline stayed in the statute. The queue did not care.

Litigants broke that backlog, not complainants. The American Hospital Association sued for mandamus, and Judge Boasberg put HHS on the hospitals’ timetable: a 30 percent reduction from the current backlog by December 31, 2017, and elimination of the backlog by December 31, 2020.

The complaint that ends in a phone call

Quality of care has a door of its own, and hardly anyone uses it. The Quality Improvement Organization decides whether your concern goes to Immediate Advocacy or a formal review. Under Immediate Advocacy it contacts your doctor or other health care provider at once on your behalf. The Centers for Medicare and Medicaid Services (CMS) is explicit that neither track is meant to punish health care providers.

Most of it ends there. Livanta’s report for its region covering January to October 2023 counted 327 beneficiary complaints, 260 Immediate Advocacy cases, and 79.51 percent resolved that way rather than by formal review.

The formal route is fussier. The Center for Medicare Advocacy points out the first condition: the complaint is in writing. Callers are told to put it in writing before anything proceeds. What comes back is a letter, and if the provider consents to disclosure it says whether the care met recognized standards of quality. Not your money, and not your care.

Who actually shows up at the nursing home

Facility complaints go to the state survey agency, and CMS’s manual sets the clock by how bad the allegation sounds. A nursing home complaint at the immediate jeopardy level requires an onsite survey within 3 business days. The tier below runs on an annual average of 15 business days, the next on 45 calendar days.

Words on the intake form decide who drives out, and when. A vague worry gets filed. A specific, dated allegation of harm gets a car in the parking lot.

What follows is uneven, and nobody pretends otherwise. ProPublica compared two homes cited at immediate jeopardy after residents died. In Hughes Springs, Texas, a resident approached the nurses’ station gagging on a cookie and died; inspectors found staff untrained for emergencies and slow to call 911; the home was fined $9,500. In North Augusta, South Carolina, a resident pulled out her breathing tube and died after doing so repeatedly over two months; that home was required to pay $305,370.

Operators say the unevenness cuts at them too. LeadingAge reports that in fiscal 2023 the average number of deficiencies on a standard survey ran from 2.7 in one midwestern state to 22.6 in one mid-Atlantic state. That mid-Atlantic state’s average per-day penalty was $127,974.37, it says, even though the state ranked third lowest for actual harm. A provider’s route to challenge a citation, it adds, is limited in scope and lacks neutrality.

Privacy, and the office that mostly writes letters

The Office for Civil Rights is not required to investigate your complaint under the Health Insurance Portability and Accountability Act (HIPAA). It will investigate when a preliminary review indicates a possible violation due to willful neglect. For everything else, it may investigate any other complaint.

The scale explains the rest. As of October 31, 2024, the office had received over 374,321 HIPAA complaints since 2003, resolving 370,578 of them and giving early technical assistance without investigation in 67,873 cases. It had settled or imposed a civil money penalty in 152 cases.

152 out of 374,321.

Penalties land, and they are specific. A mother could not get records about her unborn child from Bayfront Health St. Petersburg. The hospital paid $85,000 and adopted a corrective action plan, the first case settled under the office’s Right of Access Initiative.

The commoner shape is a letter. ProPublica found that in more than 200 instances over those four years, the office reminded CVS of its obligations or accepted its pledges to improve privacy protections, without punitive action.

You cannot take it to court yourself. The Congressional Research Service notes that the Privacy Rule lets any person file an administrative complaint but did not create a private right of action. For HIPAA, your complaint is the entire remedy.

Discrimination, and the funding threat behind it

Here the office negotiates, and what it wins is usually a changed policy. St. Francis Health Center in Kansas faced a complaint, later resolved by the HHS Office for Civil Rights, alleging that it violated Section 504 of the Rehabilitation Act by failing to provide a sign language interpreter for a deaf patient admitted for surgery. It rewrote its policy so patients are told in writing at admission of their right to an interpreter, trained staff, and installed video remote interpretation.

Nobody paid the patient. The next deaf patient gets told.

The threat behind the negotiation is federal money, and the law makes it hard to pull. Funds cannot stop until the Secretary determines compliance cannot be secured by voluntary means. Then a hearing must produce an express finding on the record, and 30 days must pass after a full written report goes to the House and Senate committees.

Three steps and a report to Congress before a single dollar stops. That is why nearly everything settles.

Section 1557 of the Affordable Care Act borrows the enforcement mechanisms of Title VI and the disability and age statutes rather than writing its own, so the office is not your only route. Individuals may generally bring a private suit for Title VI violations, though no private right of action is available to enforce the disparate impact regulations. And when the Supreme Court asked whether someone suing under Section 504 and Section 1557 could recover emotional distress damages, it read those statutes to foreclose that relief as well.

What counts as discrimination is contested, seriously so on both sides, and the rule itself keeps moving. When HHS issued its 2024 nondiscrimination rule, the preamble recorded that the rule it replaced remained in effect, save for the parts enjoined or set aside by courts. Which version governs your case depends on when it happened and which court has spoken.

Patient advocates answer that with a practical instruction. The National Health Law Program tells a patient refused care to file with the civil rights office, and adds that individuals may also go to court to privately enforce their rights and stop ongoing acts of discrimination, and that a state insurance commissioner, Medicaid agency or health ombudsman may take the complaint too.

Becket, the law firm that represented Franciscan Alliance and an association of over 19,000 healthcare professionals, describes a 2016 mandate requiring doctors to perform gender-transition procedures on any patient, even a child, where the procedure violates the doctor’s conscience. On remand the district court permanently enjoined HHS from requiring Franciscan Alliance to perform gender-reassignment surgeries or abortions against its sincerely held religious beliefs, and the Fifth Circuit affirmed that injunction.

The fraud tip that vanishes, and the lawsuit that does not

Report fraud to the inspector general and you will hear nothing back. The hotline will not be able to confirm receipt of your complaint or answer questions about action taken. Its own advice: file a Freedom of Information Act request for records, not a status check, after waiting at least six months.

Silence is not evidence of anything. It is the design.

One exception exists: a lawsuit. Ronda Osinek and James M. Taylor, M.D., both former Kaiser employees, sued under the False Claims Act’s whistleblower provisions over diagnosis coding. Kaiser affiliates paid $556 million to resolve the suit, and the relator share of the recovery will be $95 million. That is a sealed federal case, not a web form.

Whether they find out it was you, and who will help

The civil rights office says it plainly on its consent form: to investigate, it may need to reveal your identity to people at the entity under investigation. Consent is voluntary, and withholding it may close your case.

Retaliation is separately illegal. A covered entity may not threaten, intimidate, coerce, harass, discriminate against anyone for filing a complaint or helping an investigation. A nursing home resident has the right to voice grievances without discrimination or reprisal and without fear of it.

Free help exists. Every state runs a State Health Insurance Assistance Program offering one-on-one assistance, counseling, and education to Medicare beneficiaries and their families. The long-term care ombudsman must identify, investigate, and resolve complaints made by or on behalf of residents.

Does any of it change anything for anyone else

Glenda Jimmo’s case is the clearest yes in this system, with the clearest warning attached. Her class action in Vermont described an unwritten rule of thumb the plaintiffs called the “Improvement Standard”, under which claims were denied because a beneficiary was merely stable, or not improving.

The settlement made CMS rewrite the manuals so that coverage of therapy does not turn on the presence or absence of potential for improvement, but on the need for skilled care. An education campaign followed: a transmittal, a Medicare Learning Network article, new 1-800-MEDICARE scripts.

Then she had to do it again. Jimmo went back to court over her own claim, and the Secretary agreed that the Medicare Appeals Council’s decision was vacated completely, paying the claim in full: $11,586.55 to Addison County Home Health and Hospice.

Complaints move systems on a delay measured in years. After ProPublica and The New Yorker investigated hospices, CMS overhauled inspections so that surveyors must consult news reports, previous complaints and patient reviews before they begin.

Which leaves one unromantic rule. File the narrow, fast thing, in writing, before the clock runs out, and keep a copy. The office with the grandest name is rarely the one that can give you your care back.