Slide 1: My Ombudsman MassHealth Health Plans 
Presented By
Sabrina Felteau, Director and Falguni Basnet, Data Analyst
May 14, 2024
Slide 2: Agenda
•	 Review of 2023 data for One Care plans
o	 The themes and the details that emerged from our analysis of complaints that were closed in 2023
•	 Review of Q1 2024 data for One Care plans
o	The top themes that emerged from our analysis of complaints that were closed in Q1 2024
•	Key Takeaways
•	Questions/Comments
Slide 3: New Inquiry/Complaint Volume in 2023
Note: the following information is shown in an organization chart on this slide with the calls/emails at the top and the other items in two blocks below it.

•	Calls/Emails, 476
o	Inquiries,134
o	Complaints, 342
Slide 4: Unique One Care Members Assisted in 2023
Note: the following information is shown in an organization chart on this slide with the complaints/inquiries at the top and the other items in two blocks below it.

•	Of the 476 new complaints/inquiries:  
289 unique individuals
o	Returning individuals, 93
o	New individuals, 196
Slide 5: Analysis of Closed Complaints
What is a closed complaint?
•	A complaint that has reached its conclusion after providing the member with the plan's resolution
•	Member may be referred to a partner organization for further assistance 
•	Includes complaints that may have been opened in a different quarter

Why analyze closed complaints?
•	Closed complaints provide understanding of the issue from beginning to end
•	Closed complaints contain the most complete data, including demographics, resolution, and member satisfaction
•	Open complaints may evolve over time
Slide 6: Call Subjects within Closed Complaints (2023)
Themes 	Frequency
Benefits/Access	116
DME	57
Claim/Payment	35
Care Coordination/ Care Manager	33
LTSS	32
Pharmacy/Medication 	22
Transportation 	20
Physician/Hospital	15
CLAS/Accessibility	11
Home Health Agency	<10
Appeals/Grievance Process	<10
Behavioral Health	<10
Enrollment/Disenrollment	<10
Total	366

Slide 7: Top themes within closed complaints in 2023
Themes 	Frequency
Denial of a benefit or service 	64
Dissatisfaction with any general aspect of care	48
Problem finding an in-network provider	42
Delays in receiving an approved benefit or service 	42
Problems with authorization process	33
Member received a bill or had to pay a co-pay	23
Member needed guidance or support initiating 
a benefit or service	21
Member reported insufficient/inadequate Care Coordination	18
Deaf and Hard-of-Hearing Accessibility Issues 	11

Total number of closed complaints: 366
Slide 8: Denial of a benefit or service
The most common reasons for denials were administrative issues, lack of medical necessity, or the requesting of a non-covered benefit.

31% (20 out of 64) of the denials were related to dental services

The remaining denials were related to PCA (12), Medication (4), DME (4), Physical Therapy (2), Optical Services (2), and Other or unclear benefits or services.

44% (28 out of 64) the denials were resolved in the member’s favor, 17% (11 out of 64) continued to be denied after the appeal, and 39% (25 out of 64) were inconclusive due to members being unreachable.
Slide 9: Key Takeaways from 2023 Denial of Benefit Themes
•	The most common theme was related to members being denied for a benefit or service, and among those denials, members sought help with MYO regarding getting dental services approved the most. 
•	For this reason, MYO has recently updated its database to include “Dental” as a separate call subject, for better monitoring and analysis of Dental services-related cases that MYO receives. 
•	MYO places high priority to find a conclusive outcome to members’ denial cases, including reaching out to the member at least 3 times before determining the member unreachable. 
Slide 10: Dissatisfaction with any general aspect of care
What did members report as being dissatisfied with?
•	The most common complaints included members being dissatisfied with Care Coordination (11), Transportation (10), Hospitals/Physicians (9), and Home Health Services (7).
•	The remaining members were dissatisfied with LTSS (2), Behavioral Health Services (1), Medication (1), and Other Benefits or services, such as dental providers (5). 

Outcomes
•	56% (27 out of 48) of these complaints were resolved. 
•	The remaining were inconclusive, due to members becoming unreachable.
Slide 11: Problems finding an in-network provider
Subjects
•	The most common provider search cases were related to: Dental (11) and Behavioral Health (8)
•	The remaining cases were related to Eye doctor (5), PCP (5), Massage therapist (3), Other (6), Unclear (4)
•	Most of the members were looking for guidance finding a provider in these areas, while the remaining had more specific issues such as preferred providers no longer taking insurance plans, not taking new patients, or not being available in their service area. 

Outcomes 
•	55% (23 out of 42) of these provider search cases were resolved. 
•	The remaining were inconclusive due to members becoming unreachable.
Slide 12: Delays in receiving an approved benefit or service
Reasons for Delays
•	This theme includes DME (26), LTSS (6), Medication (3), and Home Health services (4) delays due to various reasons. 
•	Most prevalent reasons for the delays include insufficient communication with care coordinator, insufficient communication or miscommunication with vendors and providers, and members having difficulty finding vendors in-network.

Outcomes 
•	83% (35 out of 42) of these complaints were resolved. 
•	The remaining were inconclusive, due to members being unreachable at any point during the case.
Slide 13: Problem with authorization process
Reasons
•	Cases included authorization process issues for DME, LTSS, Medication, and Home Health service, etc, with LTSS and DME being the most prevalent subjects.
•	Prevalent reasons for the issues included pre-requisites for seeking authorization, such as completion of an evaluation or assessment not met, and provider or vendor verbally refusing member’s request for a DME, LTSS, or medication prior authorization.
•	Other reasons included prior authorizations not sent due to provider’s office or care team’s delays, prior authorization having insufficient or inaccurate information.

Outcomes 
•	70% (23 out of 33) of these complaints were resolved. 
•	The remaining were inconclusive, due to members becoming unreachable.
Slide 14: Member received a bill or had to pay a co-pay
Reasons
•	In most of these cases, the member received a bill or had to pay a co-pay because the benefit or service wasn’t covered, the bill was sent due to an administrative error, or the provider or vendor was out of network
•	The remaining reasons included provider or vendor not having member’s correct insurance information, providers refusing to send claims/other paperwork to the plan, and a gap in health insurance coverage.

Outcomes 
•	83% (19 out of 23) of the cases were resolved by MYO.
•	13% (3 out of 23) were unresolved due to the member missing the deadline for the appeal, and 4% (1 out of 23) were inconclusive due to member being unreachable.
Slide 15: Member needed guidance or support initiating a benefit or service
Benefits or Services included:
•	62% of the cases were regarding members needing guidance or support initiating a DME request.
•	The remaining cases were regarding getting started with Transportation, Care Coordination, Dental, Medication, or other: such as cardiac or pulmonary rehab services

Outcomes 
•	62% (13 out of 21) of the cases were resolved by MYO.
•	The remaining were inconclusive, due to members being unreachable at any point during the case.
Slide 16: Member reported Insufficient/Inadequate Care Coordination
Reasons
•	Members reported that their care coordinators or care teams were unresponsive or difficult to contact (83%)
•	Members also reported being unaware of care coordinator change. 

Outcomes
•	67% (12 out of 18) of the cases were resolved by MYO.
•	The remaining were inconclusive, due to members becoming unreachable.
Slide 17: Deaf/Hard-of-Hearing Accessibility Issues
Deaf/HOH Accessibility Issues
•	Deaf and Hard-of-Hearing members reported needing help with arranging interpreter services for their appointments, making sure that an interpreter is available, and arranging in-person interpreters rather than video-remote interpreting. 

Outcomes 
•	In 81% (9 out of 11) of these cases, member got the outcome they wanted, meaning that they were able to have an interpreter at their appointments.
•	In the remaining cases, the members were unreachable.
Slide 18: Other themes within closed complaints in 2023 
Themes 	Count
Transportation Issues	<10
Member required assistance with the status of a prior authorization	<10
PCA staff payment issues	<10
Enrollment Issues	<5
Other themes	24
Insufficient data 	23
Slide 19: Recalling the Agenda
First part of the presentation 
•	Review of 2023 data for One Care plans
o	The themes and the details that emerged from our analysis of complaints that were closed in 2023

Second part of the presentation 
•	Review of Q1 2024 data for One Care plans
o	The top themes that emerged from our analysis of complaints that were closed in Q1 2024

Slide 20: 
New Inquiry/Complaint Volume in Q1 2024

Note: the following information is shown in an organization chart on this slide with the calls/emails at the top and the other items in two blocks below it.

•	Calls/Emails, 127
o	Inquiries, 39
o	Complaints, 88
Slide 21: Unique One Care Members Assisted in Q1 2024
Note: the following information is shown in an organization chart on this slide with the complaints/inquiries at the top and the other items in two blocks below it.

•	Of the 127 new complaints/inquiries:  
75 unique individuals
o	Returning individuals, 23
o	New individuals, 52
Slide 22: Closed Complaints in Q1 2024: Call Subjects
Themes 	Frequency
Benefits/Access	21
DME	12
LTSS	11
Care Coordinator/Care Manager	<10
Claim/Payment	<10
Pharmacy/Medication 	<10
Appeals/Grievance Process	<10
Transportation	<10
CLAS/Accessibility	<10
Total	68
Slide 23: Top theme in Closed Complaints from Q1 2024
Themes 	Frequency
Problem with authorization process	<10

Total number of closed complaints: 68
Slide 24: Problem with authorization process (Q1 2024 top theme)
Reasons
•	Cases included authorization process difficulties for Physical therapy, DME, LTSS, Medication, and Home Health service, etc. with DME being the most prevalent subject.
•	Reasons for the difficulties included pre-requisites for seeking authorization not met, (such as completion of evaluation or assessment for PCA services), and vendor, care team or provider’s errors.

Outcomes
•	78% of these complaints were resolved. 
•	The remaining (2 complaints) were inconclusive, due to members being unreachable at any point during the case.
Slide 25: Takeaways from Q1 2024 top theme
•	The most common theme was related to members experiencing issues with the authorization process due to various reasons: 
o	Due to pre-requisites for seeking authorization not met, such as completion of evaluation or assessment for PCA services.
o	Due to vendor, provider or care team’s errors, or provider not submitting claims to the insurance plan for payment. 
Slide 26: Other themes in Q1 2024 
Themes 	Count
Insufficient/Inadequate Care Coordination	<10
Member needed guidance or support with initiating a request for a 
benefit or service	<10
Denial of a benefit or service	<10
Delays in receiving an approved benefit or service	<10
Dissatisfaction with any general aspect of care 	<10
Problem finding an in-network provider	<5
Member required assistance with the status of a prior authorization	<5
PCA staff payment issues	<5
Member received bill from a provider or vendor or had to pay a co-pay 	<5
Deaf/HOH Accessibility issues	<5
Other themes	<10

Total number of closed complaints: 68
Slide 27: Thank you!

Questions or comments?
Slide 28: Contact Us
My Ombudsman
Need help with your MassHealth benefits? We’re here for you.

•	Phone: 855-781-9898
•	Deaf/Hard of Hearing: 339-224-6831
•	Email: info@myombudsman.org
•	Web: www.myombudsman.org
•	Monday-Friday 9am-4pm

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