Understanding CHAP’s Complaint Investigation Process
Accredited providers are required to provide every client with information on how to contact CHAP should they wish to file a complaint against the organization. When CHAP receives a complaint, the information is evaluated to determine whether or not the accredited organization complies with CHAP’s Standards of Excellence ― accreditation requirements that promote high-quality patient care.
Contact 911 immediately.
CHAP encourages complainants to seek resolution with the organization before submitting a complaint to CHAP. The complaint investigation process may be lengthy and is therefore not an ideal forum for individual dispute resolution.
CHAP only investigates complaints related to CHAP-accredited organizations. We do not have authority to investigate complaints about organizations that are not CHAP-accredited. Please use the CHAP Accredited Agency Locator to find out if the organization in question is accredited by CHAP.
CHAP focuses complaint investigations on issues primarily related to patient safety, quality of care and adherence to the patient’s plan of care. Unless there is a direct impact on patient care, CHAP does not investigate complaints unrelated to CHAP accreditation standards, such as:
- Billing disputes
- Problems with insurance payment
- Employee and labor disputes
If there is no on-site investigation of the complaint, the information is retained in our system and will be noted when CHAP performs the organization’s next Site Visit.
It may take up to 90 days to conclude a complaint investigation. To ensure your issue is addressed promptly, we recommend contacting the organization directly.
No: CHAP-accredited organizations are required to notify all individuals of their right to file a formal grievance without fear of retaliation. In addition, complainants will remain anonymous throughout the entire complaint investigation, unless you choose to waive your right to confidentiality.
Complaint investigations typically begin with a phone interview of the complainant. Afterward, the Complaints Management Committee, a team composed of CHAP Directors of Accreditation, determines whether or not to conduct a Site Visit to investigate the allegations further.
A Site Visit may include staff and patient interviews, delivery of care observations, examination of relevant policies and procedures, and review of other documents and records related to the complaint. If gaps are identified, the organization will then submit a plan of correction to address all deficiencies to prevent future situations such as those that the complainant experienced. All CHAP-accredited organizations are required to cooperate in complaint investigations.
Once a complaint investigation is concluded, follow-up action is conducted with the CHAP-accredited organization if deficient practices are identified. Post-investigation follow-up may range from the organization’s submission of an acceptable plan of correction up to termination of accreditation, depending on the manner and degree of findings.
Upon request by the complainant, notification of the outcome(s) of the investigation can be provided. Information provided will include the dates of initiation and conclusion of the investigation and whether the complaint was substantiated against CHAP accreditation requirements. To file this request, contact CHAP.
CHAP only investigates complaints related to CHAP-accredited organizations. Please use the CHAP Accredited Agency Locator to find out if the organization is accredited by CHAP.
You may file a complaint by:
Mail: 1275 K Street NW, Suite 800, Washington, DC 20005 (Attn: Complaints Department)
CHAP encourages complainants to provide the following information when filing a complaint:
- Complainant’s name, phone number, and email address
- Patient’s name
- Organization’s name and address
- Service line (home health, hospice, home medical equipment (HME), etc.)
- Date(s) of the incident(s)
- Description of the incident(s) (be specific – include dates, times, frequency, etc.)
Medicare fraud is suspected when Medicare is billed for services or supplies not received.
Medicare abuse is considered when doctors or suppliers do not follow accepted medical practices leading to unnecessary costs to Medicare, improper payment or services provided that are/were not medically necessary.
Examples of possible Medicare fraud include:
- A healthcare provider charging Medicare for services never received
- A supplier billing Medicare for equipment never delivered
- A company using false information to mislead someone into joining a Medicare plan
Examples of possible Medicare abuse include:
- Using incorrect codes on a claim
- Charging excessively for services or supplies
- Billing for services that were not medically necessary
For information about how to spot and report Medicare fraud and abuse, please refer to the following websites:
To report suspected errors, fraud or abuse, contact:
Centers for Medicare & Medicaid Services(CMS) Medicare Fraud Hotline
Mail: Medicare Beneficiary Contact Center
P.O. Box 39
Lawrence, KS 66044