Member service representatives are the heart of a health plan. Their engagement with members significantly influences a member’s perceived experience with the plan and their care journey. For a Medicare Advantage plan the stakes are high. Helping Medicare members navigate an often confusing health system and ensuring they are maximizing their benefits and health outcomes is serious business, and CMS is watching at every turn.
During the 2025 program audit season BluePeak Advisors observed an increased focus on call center activities. Specifically, First Call Resolution (FCR) grievances and Quality of Care (QOC) grievances. These grievance types have become key indicators of a plan’s responsiveness and regulatory compliance.
Accurately identifying, documenting, and processing these grievances can be challenging for Member Service Representatives, especially when a member expresses dissatisfaction but declines to file a formal grievance. This article will outline these types of grievances and our most frequent questions around them.
It should be noted that while this article focuses on calls coming into member services, any representative of the plan could receive a grievance and should know how to document and respond to them.
Grievance: A grievance is defined by CMS as “any complaint or dispute (from a member or their authorized representative) expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Medicare health plan or its providers.”
First Call Resolution (FCR) Grievances
FCR grievances occur when a member expresses dissatisfaction during a call, and the issue is resolved during that same interaction. Even if the member does not request to file a grievance, CMS considers this a grievance that should be documented as such and show up on your grievance universe.
Example: A member calls the plan and is frustrated because their doctor took a $25 copay, and they believe they only have a $20 copay. The customer service representative (CSR) confirms the $20 copay by three-way calling the doctor’s office. The doctor’s office agrees to credit the member their $5. The member is satisfied with the outcome of their complaint.
Why is this a First Call Resolution grievance?
The member complained about their doctor taking the wrong copay amount. While the CSR was able to resolve the complaint during the initial call and no additional action was required, it is still imperative to track and trend the grievance. This grievance should be marked as resolved and should show up on the Part C grievance universe.
Quality of Care (QOC) Grievances
QOC grievances involve complaints about the clinical care received from a provider or facility. These can be reported through the plan’s grievance process, the Beneficiary and Family Centered Care – Quality Improvement Organization (BFCC-QIO), or both. Quality of Care grievances follow a specific process outlined in CMS guidance and are researched and responded to differently than other grievance types.
Example: In the course of talking with a member about their recent hospital visit, the member mentions that they had acquired bed sores, and the nurses didn’t address them.
Why is this a Quality of Care Grievance?
The member mentions dissatisfaction with the care they receive related to acquiring and caring for bed sores. This potential quality of care issue should be thoroughly investigated, even if the member does not request a grievance to be filed. Quality of Care grievances are never first call resolution grievances as someone from the plan must investigate all potential QOCs. These grievances should show up on the grievance universe.
Common Q&A
Q: Wouldn’t just about every phone call be a first call resolution grievance?
A: No, however, many calls are. The key is to train your CSR to target the difference between an inquiry and a statement of dissatisfaction. Often dissatisfaction can be equated to an error that was made or perceived to be made or an expectation that was not met.
Q: Do I have to ask a member if I can file a grievance?
A: Discussing filing a grievance with a member should be more of a statement than a question. “Thank you for sharing this information. I am going to file a grievance on your behalf.”
- For FCR grievances the CSR can also add, “We track and trend our member concerns in an effort to improve quality and future experiences”.
- For QOC grievances the CSR can add, “we will look into this matter and address it as necessary.”
Q: What if the member states they do not want a grievance filed?
- Often times, explaining the grievance process and what to expect will ease any concern with filing a grievance. However, if a member still does not want to file a grievance:
- Quality of Care grievances should always be documented and investigated, even if the member does not want a grievance to be filed. Your plan should have a clear workflow for the MSR to note to the investigator that the member did not want to file a grievance.
- All other types of grievances should be filed as first call resolution grievances, with the resolution specifically stating that the member did not wish to file a grievance and the grievance is for tracking and trending purposes only. FCR grievances should not get resolution letters.
- What if the member’s quality of care grievance is potentially putting the member at risk of harm or death?
- Your plan should have a clear process in place for the MSR to engage a clinician at the plan in the utilization management or case management department to assess the immediate risk and take appropriate action. Once immediate risk is resolved, the QOC should go through the normal review process as a grievance.
Q: Should we do any oversight of first call resolution grievances?
A: Absolutely. Quality monitoring should include sampling FCR grievances to ensure they were documented correctly and fully resolved. All monitoring of grievances should also include looking for other request types such as appeals or determination requests. Listening to the FCR call when evaluating it is key.
How can BluePeak Advisors help?
Partnering with your member services team is critical in reducing risks associated with missing or incorrectly processing grievances. BluePeak Advisors has senior consultants who have worked in member services, grievance departments and compliance for the bulk of their careers. Our experts can help you:
- Develop a training curriculum to ensure an understanding of grievance processes
- Review grievance universes and call logs to identify potential outliers or risks
- Audit grievance calls and the full grievance process. This includes listening to the call, reviewing the documentation and validating the resolution.
