Office of Health Care Ombudsman and Bill of Rights (OHCOBR)
FY2014 Summary of Cases October 1, 2013 through September 30, 2014
The Knowledge to Guide You Slide 2 Office of Health Care Ombudsman
and Bill of Rights (OHCOBR)Highlights - FY2014 Contact Summary
Table of Contents Highlights FY2014 Contact Summary 3 Summary of
Activities FY2014 4 Number and Percentage of Opened Cases Among All
Contacts(Non-Commercial); (Commercial-Non-Appeals/Grievances-Bill
of Rights); and (Commercial-Appeals/Grievances-Bill of Rights) 5-6
Number and Percentage of Closed/Resolved Cases Among
(Non-Commercial) Contacts 7-8 Number and Percentage of
Closed/Resolved Cases Among (Commercial-Non-Appeals/Grievances-Bill
of Rights) Contacts 9-10 Number and Percentage of Closed/Resolved
Cases Among (Commercial-Appeals/Grievances-Bill of Rights) Contacts
11-12 Methods of Contacting OHCOBR 13-14 Categories of Contacts by
Insurance Type 15-16 Contacts by Wards and States Located Within
the DC Metropolitan Area and States Located Outside of the DC
Metropolitan Area 17-18 Breakdown of Types of Issues Encountered by
All Contacts(Non-Commercial);
(Commercial-Non-Appeals/Grievances-Bill of Rights);
and(Commercial-Appeals/Grievances-Bill of Rights) 20-21 Breakdown
of Types of Issues Encountered by (Non-Commercial) Contacts 22-23
Breakdown of Types of Issues Encountered by
(Commercial-Non-Appeals/Grievances-Bill of Rights) Contacts 24-25
Breakdown of Types of Issues Encountered by
(Commercial-Appeals/Grievances-Bill of Rights) Contacts 26-27
Breakdown of Dispositions Among All
(Commercial-Appeals/Grievances-Bill of Rights) Contacts 28
Breakdown of Types of Issues Encountered by Dual Eligible (Medicare
and Medicaid) Contacts 29-30 Breakdown of Types of Issues
Encountered by Medicaid (Fee For-Service) Contacts 31-32 Breakdown
of Types of Issues Encountered by Medicare Part A; Part B; Part
A/B; Part A/B (QMB) Contacts 33-34 Breakdown of Types of Issues
Encountered by Medicaid Managed Care (MCO) Contacts 35-36 Breakdown
of Types of Issues Encountered by Alliance Contacts 37-38 Breakdown
of Types of Issues Encountered by Uninsured Contacts 39-40
Breakdown of Transportation Contacts by Insurance Type and Issues
Encountered by Contacts 41-44 Breakdown of EPD Waiver Contacts by
Insurance Type and Issues Encountered by EPD Waiver Contacts 45-48
Breakdown of Types of Issues Encountered by DC Health Link and
Health Exchange Marketplace Contacts 49-50 Dollar Amount of Savings
on Behalf of (Non-Commercial);
(Commercial-Non-Appeals/Grievances-Bill of Rights) and
(Commercial-Appeals/Grievances-Bill of Rights) Contacts 51-52
Average Number of Days to Close/Resolve (Non-Commercial) Cases
53-54 Average Number of Days to Close/Resolve
(Commercial-Non-Appeals/Grievances-Bill of Rights) Cases 55-56
Average Number of Days to Close/Resolve
(Commercial-Appeals/Grievances-Bill of Rights) Cases 57-58
Breakdown of Number and Percentage of How (Non-Commercial) Cases
Were Closed/Resolved by the OHCOBR 59-60 Breakdown of Number and
Percentage of How (Commercial-Non-Appeals/Grievances-Bill of
Rights) Cases Were Closed/Resolved by the OHCOBR 61-62 Breakdown of
Number and Percentage of How (Commercial-Appeals/Grievances-Bill of
Rights) Cases Were Closed/Resolved by the OHCOBR 63-64 Slide 3
Office of Health Care Ombudsman and Bill of Rights (OHCOBR)
Highlights - FY2014 Contact Summary In FY2014, the Office of Health
Care Ombudsman and Bill of Rights opened a grand total of (7,904)
Non-Commercial and Commercial cases - (See Pages 5 & 6); Of the
(7,904) cases opened - (7,712) cases were Non-Commercial - (See
Pages 5 & 6); Percentage of closed/resolved Non-Commercial
cases was (95% or 7,304 closed/resolved cases) out of a total of
(7,712) Non-Commercial cases opened) (See Pages 7 & 8); In
FY2014, the Average Number of Days for the Office of Health Care
Ombudsman and Bill of Rights to close/resolve Non-Commercial cases
was (2) days -(See Pages 53 & 54); Of the (7,712)
Non-Commercial cases opened in FY2014, the Office of Health Care
Ombudsman and Bill of Rights closed/resolved (6,472) cases on same
day that cases were opened - (See Pages 53 & 54); Of the grand
total of (7,904) cases opened by the Office of Health Care
Ombudsman and Bill of Rights (192) cases were among the Commercial
Health Plan Members (See Pages 5 & 6); Of the (192) Commercial
cases opened (59) cases were Commercial-Non-Appeals/Grievances -
(See Pages 5 & 6); Percentage of closed/resolved
Commercial-Non-Appeals/Grievances cases was (73% or 43
closed/resolved cases) out of a total of (59)
Commercial-Non-Appeals/Grievances cases opened - (See Pages 9 &
10); In FY2014, the Average Number of Days for the Office of Health
Care Ombudsman and Bill of Rights to close/resolve
Commercial-Non-Appeals/Grievances cases was (0) days - (See Pages
55 & 56); Of the (59) Commercial-Non-Appeals/Grievances cases
opened in FY2014, the Office of Health Care Ombudsman and Bill of
Rights closed/resolved (41) cases on same day that cases were
opened - (See Pages 55 & 56); Of the (192) Commercial cases
opened (133) cases were Commercial-Appeals/Grievances - (See Pages
5 & 6); Percentage of closed/resolved
Commercial-Appeals/Grievances cases was (36% or 48 closed/resolved
cases) out of a total of (133) commercial-appeals/grievances cases
opened - (See Pages 11 & 12); In FY2014, the Average Number of
Days for the Office of Health Care Ombudsman and Bill of Rights to
close/resolve Commercial-Appeals/Grievances cases was (87.7) days -
(See Pages 57 & 58); Of the (133) Commercial-Appeals/Grievances
cases opened in FY2014, the Office of Health Care Ombudsman and
Bill of Rights closed/resolved (53) cases on same day that cases
were opened - (See Pages 57 & 58); On behalf of consumers, the
Office of Health Care Ombudsman and Bill of Rights saved consumers
a total dollar amount of ($932,651.62). Of the total dollar amount
saved, $457,240.56 (49%) was from Commercial-Appeals/Grievances
cases; $25,991.07 (2%) was removed from beneficiaries accounts for
QMB (Co-Pays); $26,803.43 (2%) was for reimbursements to
beneficiaries due to non-payment of Medicare Part B Premiums; and
$422,616.56 (47%) was for Other-(Money saved or recouped for
Fee-for- Service, MCO and Alliance beneficiaries - (See Pages 51
& 52); Of the (162) Administrative/Fair Hearing cases filed by
the Office of Health Care Ombudsman and Bill of Rights (13% or 85
cases) were filed on behalf of EPD Waiver beneficiaries - (See
Pages 20, 21, 47 & 48); Most consumers utilized the telephone
to contact the Office of Health Care Ombudsman and Bill of
Rights(94% or 7,462 contacts) (See Pages 13 & 14); Most
contacts made to the Office of Health Care Ombudsman and Bill of
Rights were by Medicare Part A; Part B; Part A/B or Part A/B (QMB)
beneficiaries - (See Pages 15 & 16); Consumers from all Wards
and States located within and outside of the DC Metropolitan Area
contacted the Office of Health Care Ombudsman and Bill of Rights.
(Ward (7) had the highest number of contacts, followed by Ward (5),
and Ward (8) - (See Pages 17 & 18); Eligibility issues
represented the largest category of issues encountered by all
consumers - (See Pages 20 & 21); Eligibility issues represented
the largest category of issues encountered by MCOs and Alliance
beneficiaries (See Pages 35, 36, 37 & 38); Access/Coverage
issues (to include denials) represented the largest category of
issues encountered by Dual Eligible (Medicaid/Medicare), and
Medicaid (FFS) - (See Pages 29, 30, 31 & 32); Other issues
represented the largest category of issues encountered by Medicare
Part A; Part B; Part A/B or Part A/B (QMB) beneficiaries - (See
Pages 33 & 34); The Office of Health Care Ombudsman and Bill of
Rights opened a total of (148) Transportation Cases in FY2014,
versus the (107) Transportation cases opened in FY2013 (See Pages
41 & 42); The Office of Health Care Ombudsman and Bill of
Rights opened a total of (678) EPD Waiver Cases in FY2014, versus
the (618) EPD Waiver cases opened in FY2013 (See Pages 45 &
46); and In FY 2014, the Office of Health Care Ombudsman and Bill
of Rights opened a total of (252) DC Health Link cases - (See Pages
49 & 50). Source data captured between October 1, 2013 through
September 30, 2014 3 Slide 4 Office of Health Care Ombudsman and
Bill of Rights (OHCOBR) FY2014 Summary of Activities During Fiscal
Year 2014, the OHCOBR has tracked all communications, or contacts
received. The OHCOBR classified all contacts as cases which the
OHCOBR investigated and strived to bring closure. The OHCOBR staff
recorded all contacts in a specially designed database system
Ombudsman In-Take Data System (OIDS) that has specific categories
for classifying different cases. These findings summarize data from
the In-Take Tracking Log for the Fiscal Year 2014 (October 1, 2013
through September 30, 2014). In summarizing the activities from the
Ombudsman In-Take Data System (OIDS), the OHCOBR sought to answer
the following key questions: How do DC residents contact the Office
of Health Ombudsman and Bill of Rights? Who contacts the Office of
Health Care Ombudsman and Bill of Rights? What are the most common
issues experienced by the community? During Fiscal Year 2014, the
OHCOBR received a total of (556) contacts by individuals
(consumers) who were repeat users. The following sections present
findings from the Health Care Ombudsmans In-Take Tracking Log,
specifically: Number and Percentage of Opened Cases Among All
Contacts(Non-Commercial); (Commercial-Non-Appeals/Grievances-Bill
of Rights); and (Commercial-Appeals/Grievances-Bill of Rights);
Number and Percentage of Closed/Resolved Cases Among
(Non-Commercial) Contacts; Number and Percentage of Closed/Resolved
Cases Among (Commercial-Non-Appeals/Grievances-Bill of Rights)
Contacts; Number and Percentage of Closed/Resolved Cases Among
(Commercial-Appeals/Grievances-Bill of Rights) Contacts; Methods of
Contacting OHCOBR; Categories of Contacts by Insurance Type;
Contacts by Wards and States Located Within the DC Metropolitan
Area and States Located Outside of the DC Metropolitan Area;
Breakdown of Types of Issues Encountered by All
Contacts(Non-Commercial); (Commercial-Non-Appeals/Grievances-Bill
of Rights); and (Commercial-Appeals/Grievances-Bill of Rights);
Breakdown of Types of Issues Encountered by (Non-Commercial)
Contacts; Breakdown of Types of Issues Encountered by
(Commercial-Non-Appeals/Grievances-Bill of Rights) Contacts;
Breakdown of Types of Issues Encountered by
(Commercial-Appeals/Grievances-Bill of Rights) Contacts; Breakdown
of Dispositions Among All (Commercial-Appeals/Grievances-Bill of
Rights) Contacts; Breakdown of Types of Issues Encountered by Dual
Eligible (Medicare and Medicaid) Contacts; Breakdown of Types of
Issues Encountered by Medicaid (FFS) Contacts; Breakdown of Types
of Issues Encountered by Medicare Part A; Part B; Part A/B; Part
A/B (QMB) Contacts; Breakdown of Types of Issues Encountered by
Medicaid Managed Care (MCO) Contacts; Breakdown of Types of Issues
Encountered by Alliance Contacts; Breakdown of Types of Issues
Encountered by Uninsured Contacts; Breakdown of Transportation
Contacts by Insurance Type and Issues Encountered by Contacts;
Breakdown of EPD Waiver Contacts by Insurance Type and Issues
Encountered by EPD Waiver Contacts; Breakdown of Types of Issues
Encountered by DC Health Link and Health Exchange Marketplace
Contacts; Dollar Amount of Savings on Behalf of (Non-Commercial);
(Commercial-Non-Appeals/Grievances-Bill of Rights) and
(Commercial-Appeals/Grievances-Bill of Rights) Contacts; Average
Number of Days to Close/Resolve (Non-Commercial) Cases; Average
Number of Days to Close/Resolve
(Commercial-Non-Appeals/Grievances-Bill of Rights) Cases; Average
Number of Days to Close/Resolve (Commercial-Appeals/Grievances-Bill
of Rights) Cases; Breakdown of Number and Percentage of How
(Non-Commercial) Cases Were Closed/Resolved by the OHCOBR;
Breakdown of Number and Percentage of How
(Commercial-Non-Appeals/Grievances-Bill of Rights) Cases Were
Closed/Resolved by the OHCOBR; and Breakdown of Number and
Percentage of How (Commercial-Appeals/Grievances-Bill of Rights)
Cases Were Closed/Resolved by the OHCOBR. Source data captured
between October 1, 2013 through September 30, 2014 4 Slide 5 Figure
1. Total Number and Percentage of Opened Cases Among All
Contacts--(Non-Commercial); (Commercial-Non-Appeals/Grievances-Bill
of Rights); and (Commercial-Appeals/Grievances-Bill of Rights)
Contacts FY13 and FY14 FY13 Total Sample = 6,507 contactedFY14
Total Sample = 7,904 contacted Source data captured between October
1, 2012 through September 30, 2013 and October 1, 2013 through
September 30, 2014 FY13FY14 5 Slide 6 Table 1. Total Number and
Percentage of Opened Cases Among All Contacts--(Non-Commercial);
(Commercial-Non-Appeals/Grievances-Bill of Rights); and
(Commercial-Appeals/Grievances-Bill of Rights) Contacts FY13 and
FY14 Opened Cases Among All Contacts FY13 Totals FY13 Percent (%)
FY14 Totals FY14 Percent (%) Non-Commercial Cases623396%771297%
Commercial (Non- Appeals/Grievances) Cases 1001%591% Commercial
(Appeals/Grievances Bill of Rights) Cases 1743%1332% Total
(Non-Commercial); (Commercial-Non- Appeals/Grievances-Bill of
Rights); (Commercial-Appeals/Grievances- Bill of Rights) Opened
Cases 6,507100%7,904100% Source data captured between October 1,
2012 through September 30, 2013 and October 1, 2013 through
September 30, 2014 6 Slide 7 Figure 2. Number and Percentage of
Closed/Resolved Cases Among (Non-Commercial) Contacts FY13 and FY14
FY13 Total Sample = 6,233 contactedFY14 Total Sample = 7,712
contacted Source data captured between October 1, 2012 through
September 30, 2013 and October 1, 2013 through September 30, 2014
FY13FY14 7 Slide 8 Table 2. Number and Percentage of
Closed/Resolved Cases Among (Non-Commercial) Contacts FY13 and FY14
Closed/Resolved Cases (Non-Commercial) FY13 Totals FY13 Percent (%)
FY14 Totals FY14 Percent (%) Cases Closed/Resolved6,17899%7,30495%
Cases Not Yet Closed/Resolved551%4085% Total (Non-Commercial) Cases
C 6,233100%7,712100% Source data captured between October 1, 2012
through September 30, 2013 and October 1, 2013 through September
30, 2014 8 Slide 9 Figure 3. Number and Percentage of
Closed/Resolved Cases Among (Commercial-Non-Appeals/Grievances-Bill
of Rights) Contacts FY13 and FY14 FY13 Total Sample = 100
contactedFY14 Total Sample = 59 contacted Source data captured
between October 1, 2012 through September 30, 2013 and October 1,
2013 through September 30, 2014 FY13FY14 9 Slide 10 Table 3. Number
and Percentage of Closed/Resolved Cases Among
(Commercial-Non-Appeals/Grievances-Bill of Rights) Contacts FY13
and FY14 Closed/Resolved Cases (Commercial-Non-
Appeals/Grievances-Bill of Rights) FY13 Totals FY13 Percent (%)
FY14 Totals FY14 Percent (%) Cases Closed/Resolved9696%4373% Cases
Not Yet Closed/Resolved44%1627% Total (Commercial-Non-
Appeals/Grievances-Bill of Rights) Cases 100100%59100% Source data
captured between October 1, 2012 through September 30, 2013 and
October 1, 2013 through September 30, 2014 10 Slide 11 Figure 4.
Number and Percentage of Closed/Resolved Cases Among
(Commercial-Appeals/Grievances-Bill of Rights) Contacts FY13 and
FY14 FY13 Total Sample = 174 contactedFY14 Total Sample = 133
contacted Source data captured between October 1, 2012 through
September 30, 2013 and October 1, 2013 through September 30, 2014
FY13FY14 11 Slide 12 Table 4. Number and Percentage of
Closed/Resolved Cases Among (Commercial-Appeals/Grievances-Bill of
Rights) Contacts FY13 and FY14 Closed/Resolved Cases
(Commercial-Appeals/Grievances-Bill of Rights) FY13 Totals FY13
Percent (%) FY14 Totals FY14 Percent (%) Appeals/Grievances Cases
Closed/Resolved12773%4836% Appeals/Grievances Cases Not Yet
Closed4727%8564% Total (Commercial-Appeals/Grievances-Bill of
Rights) Cases 174100%133100% Source data captured between October
1, 2012 through September 30, 2013 and October 1, 2013 through
September 30, 2014 12 Slide 13 Figure 5. Methods of Contacting
OHCOBR FY13 and FY14 FY13 FY14 FY13 Total Sample = 6,507
contactedFY14 Total Sample = 7,904 contacted Source data captured
between October 1, 2012 through September 30, 2013 and October 1,
2013 through September 30, 2014 13 Slide 14 Methods of Contacting
OHCOBR FY13 Totals FY13 Contacts (%) FY14 Totals FY14 Contacts (%)
Appointment2
