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WHAT TO DO WHEN THINGS ARE NOT GOING WELL BETWEEN YOU AND YOUR PROVIDER 6/2008
Center for Independence of the Disabled, NY
Page 1 of 4

WHAT TO DO WHEN THINGS ARE NOT GOING WELL BETWEEN YOU AND YOUR PROVIDER

What are my rights when I am dealing with my doctor or another health care provider?
You have legal rights that include, but are not limited to:
 Being cared for with respect, without regard to health status, sex, race, color, religion, national origin,
age, marital status or sexual orientation.
 Being told by your doctor what is wrong, what can be done for you, and what will likely be the result, in
language you understand. (If your doctor accepts Medicaid or Medicare, he/she must provide translation
services.)
 Refusing care that your doctor recommends, and being told what the result may be.
 Bringing a person of your choice with you to your appointments and discussions with doctors.
 Getting a copy of your medical record, and talking about it with your doctor.
 Appointing someone (such as a relative, friend, or lawyer) to speak for you if you are unable to speak
for yourself about your care and treatment.

Does my doctor’s office have to comply with the Americans with Disabilities Act (ADA)?
As a public accommodation, the office of a health care provider must comply with the requirements of the
ADA. If you go to a provider that is not accessible, i.e. there is no elevator or ramp for wheelchair access,
bathrooms or drinking fountains are not accessible, or ASL translation, Braille or audio tape are not
provided, your doctor may be discriminating against you as a person with disabilities.

What are some things a doctor can do to make a medical office accessible?
Along with physical accessibility requirements, many simple courtesies can make the difference between an
office being accessible or not accessible to a person with disabilities:
 If your disability impairs your vision or reading ability, a staff member can read forms and other printed
information aloud and fill in your answers. Appointing someone who can speak for you is critical in this
instance to verify the accuracy of the answers filled in on your behalf.
 If your disability makes it hard to write, a staff member can write in your answers on forms.
 If your disability makes it difficult to understand complicated information, your provider or their staff
should take the time to break down instructions and explanations in a way that you can understand and
follow.
 If you are hard of hearing, the doctor can write down information for you, speak more clearly and stand
where you can see him or her talking. (If your doctor accepts Medicaid or Medicare, he/she must
provide translation services, including American Sign Language (ASL) interpretation.)
 If your disability makes it hard to move around, the staff can bring things to you and treat you in a
different room that is more accessible as long as your medical and privacy needs can be met there.
 If you have difficulty getting onto equipment, such as an examining table, staff can physically assist
you, and should be trained to do so safely.

Can a doctor refer me to a different doctor because I have a disability?
Not if that is the only reason for the referral. In general, whether or not you have a disability, a doctor
should refer you to another provider only if your condition or the treatment you need are outside the
doctor’s knowledge and experience.

How can I work directly with my doctor to improve my treatment?
Tell the doctor that you are not satisfied with your care, and need to discuss how to improve it. If you
can, be specific about what is bothering you about his or her behavior, such as:
 Not understanding your history or your disability
 Lack of thoroughness in examining you

This information is only for members of Medicaid managed care plans, Family Health Plus, and Child Health Plus B in
New York. Commercial managed care plans may have different rules.
WHAT TO DO WHEN THINGS ARE NOT GOING WELL BETWEEN YOU AND YOUR PROVIDER 6/2008
Center for Independence of the Disabled, NY
Page 2 of 4

 Not enough communication between you and your provider, in words you can understand
 General lack of respect or patience with you
 Not believing what you report, particularly pain.

Suggest solutions to improve your quality of care.
 Share information with the doctor on how to meet your disability-related needs.
 Keep notes for yourself on conversations with your provider, and look back at them during later
discussions about your care.

What can I do if I want treatment that my doctor does not recommend?
There are situations where you may disagree with your doctor about how to treat your condition. Some
common ones are:
 You know of another treatment that you believe may help you, but your doctor does not want to use it.
 Your doctor feels nothing can be done about your condition, such as chronic pain, and you want to find
new information for treatment.
 Your doctor is a specialist in one way of treating your condition, such as surgery, and you want to find
another way.

You have a right to refuse your doctor’s preferred form of treatment. In this situation, your doctor should go
with the form of treatment he or she believes is next best. However, if your doctor is not helpful in this
situation, you will need to find another medical professional who will take your side. If you have a
symptom, such as fatigue or pain, which the doctor has not been successful in treating; your own
experience can help to show that you need a different plan of treatment.

What can I do if I have trouble with my doctor’s office staff?
Some problems have nothing to do with the doctor, and are really caused by the office staff. These may
include:
 Trouble getting answers over the telephone
 Not being able to get an appointment when you need it
 Lack of courtesy when you are waiting in the office.

Let your doctor know if you have problems with staff members in his or her office. The doctor can often
help make the staff be more responsive to your needs.

How can I get my Medicaid managed care plan help improve the service I am getting from my
doctor?
If talking to your doctor doesn’t help, or you can’t reach him or her, contact the member services
department of your Medicaid managed care plan for assistance.
 Explain the problem and the steps you have taken to correct it. This is where it is helpful to refer to
your notes on when you talked to the doctor and what was said between you.
 Ask the health plan what they will do, if anything, to help you. Make a note of the name of the
person you talk to at the health plan, when they plan to act, and what they said they would do.
 If the matter is urgent, ask them to make a three-way call to the provider while you are still on the
phone.
 If you are not happy with the results, tell the member services representative that you want to file a
formal complaint. Ask for your plan’s official procedure for filing complaints.

What is a formal complaint, and why would I make one?
Find out from the member services department of your plan or from your member handbook how to “file a
grievance” about your provider’s behavior or care. You can do so by telephone and/or on paper. It is best

to follow up a telephone complaint with a written version, so that you have proof you made the complaint.
If your doctor is refusing services because they were not considered “medically necessary,” ask for a
“utilization review” instead of “filing a grievance.”

What can I do if my disability makes navigating the grievance procedure difficult?
Under the Americans with Disabilities Act, if you require an accommodation to navigate grievance or
complaint procedures, your plan must provide it. Examples of accommodations may include:
 Help in filling out forms if your disability, like traumatic brain injury, makes it difficult for you to explain
your complaint;
 Alternate methods of communication, including TTY.

You have the right to an advocate outside the plan if you are not comfortable with the accommodations
the plan provides. The list at the end of this fact sheet includes advocates who can help you in these
circumstances.

Can I change providers if I am not happy with their services?
For any provider other than your primary care provider (PCP), you can ask your PCP to refer you to another
provider from the Medicaid managed care plan’s network. For services that do not require a referral, such as
women’s healthcare, you may change providers any time without a referral.

Some plans limit how often you can change PCPs "without cause." They must let you switch PCPs at least
every six months, even without a reason. Many will let you switch more often. You are always allowed to
change PCPs if you have a reason, such as needing a doctor with more experience treating your illness or
people with your disability.

What kinds of behavior from my doctor are considered “professional misconduct”?
Sometimes bad behavior crosses the line and can be considered negligence, incompetence, or an illegal or
unethical practice. Cases of professional misconduct should be reported to the state Department of Health’s
Office of Professional Medical Conduct, at 800-663-6114. Consider reporting a provider who:
 Performs professional services that you have not authorized
 Deliberately harasses, abuses, or intimidates patients
 Refuses to make your medical records and X-rays available to you or another provider after you have
asked for them
 Exhibits any type of inappropriate sexual conduct, verbal or physical.

What if my complaint is about a service provider who is not my doctor?
You should begin by contacting the member services department of your Medicaid managed care plan. If
you do not receive satisfaction through your plan, you can register complaints with the agencies that
oversee the provider:
 Complaints about nurse practitioners should be directed to the New York State Education Department;
complaints about Physician’s Assistants should be directed to the State Department of Health.

What can I do if my health plan makes a decision against me, in my doctor’s favor?
 Find out from the member services department or from your member handbook how to “appeal” the
decision about your grievance or utilization review. If your appeal is denied because the plan said a
service is not medically necessary, you can go on to an “external” appeal. This means your case will be
decided by impartial experts from outside of your plan.

 If you have Family Health Plus or Medicaid (either fee-for-service or managed care), you can appeal a
denial or reduction of services by requesting a fair hearing. Make sure you file your request for an

appeal within 60 days of the date on your denial or reduction of services notice. If you are already
getting services and want to avoid having them reduced while you wait for a fair hearing, you must
request a fair hearing within 10 days of the date on your reduction notice AND ask to receive “aid-to-
continue” while your case is being appealed. You can bring an advocate and/or witnesses, such as
caseworkers, relatives, friends, and/or doctors, to the hearing to help make your case. However, if the
plan is denying or reducing your services on your doctor’s recommendation, you must go through the
plan's grievance or utilization review appeals process before you can request a Fair Hearing. You can
ask for a Fair Hearing and an external appeal at the same time. If they result in opposite decisions, the
Fair Hearing decision will overrule the external appeal decision.

Can I change plans because I am not satisfied with my care?
Any member of a Family Health Plus or Medicaid managed care plan can change to a different company’s
managed care plan in the first 90 days after signing up. After that, you normally have to wait 9 months
before changing to a different plan. However, if you have tried other remedies for a problem you’re having
with your provider, you may be permitted to change plans for “good cause” before the nine months are
over. Members of Child Health Plus B plans can change health plans at any time. Make sure you find a
new plan that appears to be better before you leave the old plan.

For additional information about your rights or for assistance accessing health care:
 CIDNY’s Managed Care Consumer Assistance Program: 212-674-2300 (voice) or 212-674-5619 (TTY)
 New York State Department of Health, Office of Managed Care at 800-206-8125
 New York Medicaid CHOICE HelpLine at 800-505-5678 (1-800-774-4241 if you have SSI)
 Office of the Attorney General of the State of New York, Health Care Helpline: 800-771-7755 — option 3
(voice); 800-788-9898 (TTY).

This information is only for members of Medicaid managed care plans, Family Health Plus, and Child Health Plus B in
New York. Commercial managed care plans may have different rules.