Health 411: Several options for lodging patient complaints

I had arthroscopic knee surgery 18 weeks ago. The pain is 100 times worse than it was before surgery and has made sleeping impossible. On my first post-surgery visit, I asked the surgeon why there was a space in my knee that wasn’t there before. All he said was, “I didn’t do that.” I call and leave messages, but none has ever been returned. The pain has ruined my life, and loss of sleep has turned me into a zombie. I believe the surgeon should take responsibility for his actions, but he is unwilling to have any contact with me. What are my options?

First you should seek help for your pain, suggests Dr. Michael Carome, deputy director of the Health Research Group at Public Citizen in Washington, D.C., a nonprofit consumer advocacy organization.

The letter writer “may need to seek another provider who will hopefully evaluate the current symptoms, the care he previously received and recommend a treatment plan to help his pain,” Carome says.

To get the surgeon to accept responsibility for his actions, there are a number of steps you can take.

A physician who no longer wishes to treat a patient is required to notify him or her in writing. The doctor also needs to refer the patient to another physician and provide him or her with information about how to access the medical records that were compiled during treatment. Failure to do so amounts to patient abandonment, an infraction that would justify an investigation by the state medical board.

It’s important that a complaint is filed “if a patient believes the quality of care that they received was poor or not the standard of care they should have received,” says Jennifer Simoes, a spokeswoman for the Medical Board of California in Sacramento.

Complaints can also be lodged with state medical societies. You can find a list of them on the American Medical Assn.’s website, https://www.ama-assn.org (click on the “Patients” tab to find the Medical Society Directories).

If the surgery was done at a hospital, you can file a complaint there as well. Many hospitals have patient ombudsmen whose job is to address patient complaints.

In the likely event that the hospital is accredited by the Joint Commission — a non-governmental agency that accredits and certifies medical facilities throughout the country — you can file a complaint there.

According to Michael Kulczycki, executive director of the Joint Commission’s Ambulatory Care Accreditation Program, his organization’s Office of Quality Monitoring fields consumer complaints that are used to determine if a hospital is out of compliance with its accreditation standards. In a situation like this, he says, “we would focus on the continuity of care and appropriate follow-up to the patient.”

If appropriate, the Joint Commission would bring the situation to the attention of the hospital, which in turn would be asked to examine the physician’s behavior to determine if further action is needed. You can file your complaint online at https://www.jointcommission.org. Go to Report a Complaint About a Health Care Organization in the Action Center box on the home page.

If you have Medicare, you can contact your regional Medicare Quality Improvement Organization (QIO). These organizations review medical care and help consumers with complaints about the quality of care they received. You can find the QIO near you by visiting https://www.ahqa.org and clicking on QIO Locator.

Some state insurance commissioners might step in if your care was covered by a private insurer, Kulczycki adds.

Finally, if you feel the doctor engaged in negligence or malpractice, talk to a lawyer. “Ultimately another way physicians are held accountable is through litigation,” Carome says.

I’d like to know all the health insurance options for persons with preexisting conditions who are not eligible for Medi-Cal or Medicare.

Although you say you’re not eligible for Medi-Cal (California’s Medicaid program) or Medicare, it’s worth checking to make sure you’ve uncovered all the public and/or low-cost private programs available. Many people are eligible for some kind of publicly funded health program but don’t know it.

Case in point: A survey of 19,000 uninsured patients seeking care in four San Diego hospital emergency rooms found that nearly 80% were unknowingly eligible for some form of government insurance.

The survey, which is ongoing, is conducted by the Foundation for Health Coverage Education, a San Jose-based organization that helps people find insurance. Ankeny Minoux, the foundation’s president, says the results represent good news because most people who sought care in those emergency rooms can sign up for a federal, state or county program.

You can take the foundation’s Health Coverage Eligibility Quiz to learn about the public and private insurance offerings that might be available to you. The quiz is on the foundation’s home page, https://www.coverageforall.org.

If you’ve recently lost employer-sponsored health insurance, you may be eligible for COBRA benefits, says Bruce Benton, president-elect for the National Assn. of Health Underwriters. Just be prepared for some sticker shock: “COBRA is expensive because it’s the rate the employer was being charged [the premium you paid and what your employer kicked in] plus a small 2% administrative fee for federal COBRA and 10% for California COBRA,” says Benton, who is also executive vice president for Genesis Financial & Insurance Services in Tarzana.

If you’ve exhausted your COBRA benefits, federal law guarantees you a plan in the private insurance market, regardless of your health status. The type of plan you’ll have access to varies by state.

In California, health insurance companies that sell individual policies are required to make their two most popular plans available to people coming off COBRA, Benton says. Make sure that you receive a letter from your previous insurance company stating you’ve had coverage for at least 18 months. This is called a Certificate of Creditable Coverage, and you’ll need it in order to qualify for what’s called a HIPAA plan.

And although insurance companies are notorious for turning away consumers trying to buy coverage on their own, don’t automatically assume that a preexisting health condition will disqualify you. According to Minoux, if your condition is fairly mild and well controlled, there may be carriers willing to extend coverage. She advises people to work with an experienced insurance broker. “Brokers know the carriers and have had experience submitting applications and know which one will accept what,” she says.

You can find a licensed insurance agent in your area at the National Assn. of Health Underwriters website. Go to https://www.nahu.org, click on “Consumer Information” and choose “Find an Agent.”

If you’re in business for yourself, it’s possible to get group coverage. According to Benton, small business owners with as few as two employees can qualify for a group plan. These plans are “guaranteed issue,” meaning coverage is assured even if employees have preexisting health conditions. However, insurers can charge more because of their health status. The size of that mark-up depends on state law; in California, rates cannot be raised more than 10% above the standard-risk rate, Benton says.

Finally, in 2010 the Affordable Care Act made federally funded high-risk insurance pools available to people who could not obtain insurance on the private market. These plans, called Pre-Existing Condition Insurance Plans (PCIP), are administered by federal or state governments. California operates its own PCIP along with the Major Risk Medical Insurance Program (MRMIP), the high-risk pool that existed before healthcare reform.

To qualify for PCIP, you must be a U.S. citizen, have a preexisting health condition and be uninsured for at least six months before applying. MRMIP eligibility requirements are different: Although there can be a waiting list, you don’t need to be uninsured for any period of time. However, premiums tend to be much higher and benefits aren’t as robust as with PCIP.

You can find information about these plans — including benefits and premium rates as well as how to apply — by checking with your state’s health department or by visiting pcip.gov. You can also call the PCIP assistance center at (866) 717-5826.

Zamosky has been writing about how to access and pay for healthcare for more than 10 years.

Got a healthcare dilemma? Email health411@latimes.com or write to Health 411, Los Angeles Times Health, 202 W. 1st St., Los Angeles, CA 90012.