Provider Complaint Investigations Process

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.

What types of complaints are investigated?

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.

What is the CHAP complaint investigation process?

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.

How do I report Medicare fraud and abuse?

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 website:ss

https://www.medicare.gov/basics/reporting-medicare-fraud-and-abuse

To report suspected errors, fraud or abuse, contact:

Centers for Medicare & Medicaid Services(CMS) Medicare Fraud Hotline

Call: 800.633.4227
TTY: 877.486.2048
Mail: Medicare Beneficiary Contact Center
P.O. Box 39
Lawrence, KS 66044