Slide 1: My Ombudsman MassHealth Health Plans
Presented By
Leslie Diaz, Director and Falguni Basnet, Data Analyst
November 14, 2023
Slide 2: Agenda
•	Review of Quarter 2 and 3 2023 data for One Care plans
o	The number of individuals assisted in quarters 2 and 3
o	Inquiries and complaints opened in quarters 2 and 3
o	The themes and the details that emerged from analysis of complaints that were closed in quarters 2 and 3 
•	Key Takeaways
•	Questions/Comments

Slide 3: One Care Members Assisted per Quarter
Quarter 2 (April-June 2023)
•	108 individuals contacted MYO
•	58 were new members who contacted us for the first time
•	28 inquiries and 110 complaints (138 calls)
Quarter 3 (July-September 2023)
•	76 individuals contacted MYO
•	43 were new members who contacted us for the first time
•	25 inquiries and 72 complaints
(97 calls)
Slide 4: New One Care Inquiries in Quarter 2 and 3

Inquiry Subject​	Quarter 2
(April-June 2023)	Quarter 3
(July-September 2023)	
General Information	12	Less than 10	
Benefits/Access	Less than 10	10	
All others (<10 inquiries each) *	16	14	
TOTAL INQUIRIES​	28	24	

*Includes inquiry subjects: Benefits/Access, Physician/Hospital, Enrollment/Disenrollment, Claim/Payment, Transportation, LTSS, Home Health Agency, CLAS/Accessibility, Care Coordination/Care Manager, DME, Appeals/Grievance Process

Slide 5: New One Care Complaints in Quarter 2 and 3
Complaint Subject​	Quarter 2
(April-June 2023)	Quarter 3
(July-September 2023)	
Benefits/Access	38 	19	
DME	13	13	
Pharmacy/Medication	11	Less than 10	
Other (less than 10 complaints each) *	48	40	
TOTAL COMPLAINTS	110	72	

*Includes complaint subjects:  LTSS, Claim/Payment, Care Coordination/Care Manager, Transportation, Physician/Hospital, Home Health Agency, CLAS/Accessibility, Behavioral Health, Enrollment/Disenrollment, Appeals/Grievance Process, Pharmacy/Medication
Slide 6: 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 7: Themes within Complaints Closed in Q2 
Themes 	Frequency	
Denial of a benefit or service 	22	
Dissatisfaction with any general aspect of care	16	
Problem finding an in-network provider	16	
Other (<10 each)	49	
Slide 8: Top Theme in Q2: Denial of a Benefit or Service
•	8 dental service denials
•	Other service denials were related to, e.g., PCA services, medications, glasses, PT, etc.
Slide 9: Top Theme in Q2: Denial of a Benefit or Service
Top denial reasons
•	Lack of medical necessity: 9
•	 Not a covered benefit or service: 3
Slide 10: Top Theme in Q2: Outcomes of Dental Denial Complaints
•	In 6 out of the 8 denials, the member filed an appeal, and the service was approved.
•	In 2 out of the 8 denials, the member’s appeal was denied. In one case, the provider pursued an alternative treatment plan. In another, the member declined further assistance.
Slide 11: Themes within Complaints Closed in Q3
Themes 	Frequency	
Denial of a benefit or service 	16	
Delays in receiving an approved benefit or service	14	
Other (<10 each)	65	

Total number of closed complaints: 91
Slide 12: Top Themes in Closed Complaints (Q3)
1.	Denial of a benefit or service
2.	Delays in receiving an already approved benefit or service.
Slide 13: Theme 1: Denial of a Benefit or Service (Q2)
•	4 DME denials
•	3 dental service denials
•	3 PCA denials
•	6 Other
Slide 14: Theme 1: Denial of a Benefit or Service (Q3)
Top denial reasons
•	Lack of medical necessity: 13
•	Not a covered benefit or service: 1
•	Unknown (member unreachable): 2
Slide 15: Theme 1: Outcomes (Q3)
•	In 7 out of 16 complaints, the member was able to receive the benefit or services.
•	In 5 out of 16 complaints, member did not receive the benefit. 
•	In the remaining complaints, the outcome is unknown because the member became unreachable, or decided not to pursue the matter.
Slide 16: Theme 2: Delays (Q3)

•	6 DME delays
•	3 medication delays
•	Remaining: LTSS, home health services, other
Slide 17: Theme 2: Outcomes (Q3)
•	In 12 out of 14 complaints, the member was able to receive the benefit or services.
•	In the remaining 2 complaints, the outcome is unknown because the member became unreachable.
Slide 18: Key Takeaways from Quarter 2 Data:
•	Top themes in complaints closed
•	Denials of benefits and services, mostly dental services
•	The most common denial reason was lack of medical necessity

•	In 6 out of the 8 dental denials, the member filed an appeal, and the service was approved.

•	In the remaining 2 dental cases, the member filed an appeal, and it was denied.
Slide 19: Key Takeaways from Quarter 3 Data:
Top themes in complaints closed.
•	Denials of benefits and services (no particular type)
•	Delays in receiving approved benefits or services.

The most common denial reason was lack of medical necessity.
•	7 out of 16 denials were resolved in the member’s favor (member received the benefit).
•	The remaining outcomes are mostly unknown due to member becoming unreachable or deciding not to pursue the issue.

Reasons for delays in receiving approved services varied.
•	In 12 out of 14 of these complaints, member ultimately received the benefits or services
•	In the remaining 2 cases, member became unreachable.
Slide 20: Thank you!
Questions or Comments

Slide 21: My Ombudsman MassHealth Health Plans

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