How to File Complaints with Licensing Boards or Insurers

How to File Complaints with Licensing Boards or Insurers

When your healthcare provider or insurance company crosses the line

Sometimes, simply appealing a denial isn’t enough. When a provider acts unethically, or an insurer repeatedly violates regulations, filing a formal complaint is the next step in holding them accountable.

This guide walks you through who to report to, what to include, and how to make your complaint count.

1. When to File a Complaint

You may want to file a complaint if you experience any of the following:

Against a Healthcare Provider

  • Medical gaslighting, neglect, or refusal of care

  • Retaliation after advocating for yourself

  • Failure to document, falsifying records, or altering medical charts

  • Discrimination or violations of patient rights

  • Prescribing or medication errors

  • Inappropriate conduct or breach of confidentiality (HIPAA)

Against an Insurance Company

  • Unfair denials or delays that ignore regulations

  • Failure to follow appeal procedures or respond on time

  • Misrepresentation of benefits or coverage

  • Harassment or intimidation by insurer staff

  • Unfair network practices, including refusal to contract with needed specialists

  • Systemic pattern of wrongful denials or discrimination

💡 Tip: Always start by gathering evidence — denial letters, emails, call logs, provider notes, and copies of your appeals. Complaints carry more weight when backed by documentation.

2. Where to File Complaints

A. Provider Licensing Boards

Each healthcare professional is regulated by a state licensing board.
Find your state’s board by searching:

“(Your State) Medical Board Complaint” or “(Your State) Nursing Board Complaint”

Examples:

  • Physicians: State Medical Board

  • Nurses: Board of Nursing

  • Pharmacists: Board of Pharmacy

  • Therapists/Social Workers: Behavioral Health or Counseling Board

🔹 Include:

  • Provider’s full name and license number (if available)

  • Dates of incidents and facilities involved

  • Description of what happened and how it affected your care

  • Copies of medical records, messages, and related complaints

🔹 What Happens Next:

  • Board reviews your submission

  • May request more info or interview you

  • If serious, they open an investigation and notify the provider

B. Insurance Companies & Oversight Agencies

1. File with the Insurance Company

Every insurer has a grievance or complaint department.
Look for “Grievances and Appeals” on their website or member handbook.

Provide:

  • Your name, plan ID, and claim number

  • Summary of the problem and steps you’ve taken

  • Copies of denial letters and appeal responses

  • What resolution you are requesting

2. File with Your State’s Insurance Department

If the insurer ignores or mishandles your complaint, contact your:

State Department of Insurance (sometimes called “Department of Financial Services”)

They oversee regulatory compliance and consumer protection.
You can usually submit online or by mail.

Include copies of all correspondence and note the timeline of your case.

3. For Medicare, Medicaid, or Dual Plans

  • Medicare Advantage / Part D:
    Contact 1-800-MEDICARE or submit via Medicare.gov Complaints.

  • State Health Insurance Assistance Program (SHIP):
    Offers help filing grievances or appeals.

  • Medicaid:
    File with your state Medicaid agency or Inspector General if fraud or abuse is suspected.

C. Other Helpful Oversight Agencies

Issue TypeWhere to File
Disability discriminationU.S. Department of Health & Human Services (HHS) Office for Civil Rights (OCR)
Fraud or billing misconductHHS Office of Inspector General (OIG)
HIPAA privacy violationsHHS Office for Civil Rights (OCR)
Hospital or facility quality of careState Department of Health or CMS (Centers for Medicare & Medicaid Services)
Repeated insurer noncomplianceNational Association of Insurance Commissioners (NAIC)
Pharmacies or compounding concernsState Board of Pharmacy / FDA MedWatch

3. How to Write an Effective Complaint

A strong complaint is factual, organized, and supported by documentation.

Structure:

  1. Introduction: Who you are and why you’re writing.

  2. Background: Brief timeline of events.

  3. Main Issue: What went wrong and how it affected your health or finances.

  4. Evidence: List of attached records, letters, or call notes.

  5. Request for Action: What outcome you’re seeking (investigation, reimbursement, corrective action, etc.).

📄 AKG Advocacy Tip: Use a calm, professional tone — stick to facts, not emotion. Let the documentation tell your story.

4. After You File

  • Keep a copy of everything submitted.

  • Note the submission date and confirmation number.

  • Follow up if you haven’t heard back within 30 days.

  • For regulatory boards, investigations can take several months — be patient but persistent.

  • If retaliation occurs, document it immediately and consider adding it to your complaint or filing a new one.

5. Advocacy Resources

6. AKG Advocacy Tools

🧾 Templates:

  • Provider complaint letter

  • Insurance grievance form

  • Patient rights checklist

📘 Guides:

  • “Insurance Denials 101”

  • “Advocating Starts at Your Doctor’s Office”

  • “Understanding Your Patient Bill of Rights”

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