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What is a Medicare Beneficiary Ombudsman?

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By Daniel Petkevich
Apr 11, 2023

If you want to make an appeal or lodge a complaint, talk to your MBO

At Fair Square, we want to give you the tools to be your own best advocate. This advocacy starts when you pick your best-fit Medicare plan with a licensed Medicare advisor at

Fair Square

, but it is an ongoing process.

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If you need to file a complaint or grievance with Medicare, that is where the Ombudsman comes in. In this blog post, we will talk through the steps you need to take if you’re looking to file a complaint with your local Medicare office. Without knowing how to levy a complaint, you might find yourself missing out on coverage or adequate financial assistance. 

What is a Medicare Ombudsman?

A Medicare Beneficiary Ombudsman, or MBO, is a person within the Centers for Medicare and Medicaid Services (

CMS

) who ensures that Medicare beneficiaries receive fair treatment within their Medicare rights. Think of them as a neutral party within the CMS that acts as an advocate for you if you feel as though you’ve been mistreated. 
If you are interested in seeking an appeal for a Medicare decision related to services or coverage, then the MBO can help you file your grievance. While they are employed by the CMS, they work within specific localities and serve as an independent advocate. So you don’t need to be concerned about the MBO siding with Medicare over whatever issue you raise about your healthcare.
Some of the range of services your local MBO might offer include:
  • Helping Medicare beneficiaries navigate the system and respond to issues related to coverage, claims, and billing
  • Providing information about your Medicare benefits, rights, and protections
  • Helping beneficiaries file complaints and appeals related to their Medicare services and coverage
  • Educating Medicare beneficiaries about fraud and abuse in Medicare, including strategies about how to protect yourself
Your local MBO might also work to identify and address systemic issues that arise within

Medicare

and propose strategies and recommendations to fix them.

Why would I need to contact a Medicare Ombudsman?

If you are unsatisfied with your quality of care, you might contact your MBO. Original Medicare has a standard of care that needs to be upheld with each plan. Private insurance companies administer both Medicare Supplement and Medicare Advantage plans, but they need to maintain the government's standard of Medicare.
You might need to contact the Medicare Ombudsman if you have any issues or complaints about your Medicare coverage or services. Here are some situations where beneficiaries might need to contact Medicare Ombudsman:
  • You are having difficulty accessing the healthcare services or treatments you need.
  • You are experiencing delays or denials in getting Medicare coverage for a particular service or treatment.
  • You are dissatisfied with the quality of care you are receiving from a healthcare provider or facility.
  • You have concerns about the accuracy of your Medicare claims or bills.
  • You are having difficulty navigating the Medicare system and need assistance with enrollment or understanding your benefits.
Here are some common issues and complaints that the Medicare Ombudsman can help with:
  • Denials of coverage for medically necessary services or treatments
  • Delays or denials in receiving prescription drugs or durable medical equipment
  • Billing errors or disputes
  • Quality of care issues, such as hospital infections or medical errors
  • Issues related to Medicare Advantage or prescription drug plans
  • Complaints about Medicare marketing or enrollment practices
  • Difficulty navigating the Medicare system or understanding your benefits
The Medicare Ombudsman is available to help beneficiaries resolve these issues and can provide information, support, and advocacy. They can also guide the Medicare complaint and appeal process and help you understand your rights and protections under Medicare.

How to contact a Medicare Ombudsman

If you want to contact your Medicare Beneficiary Ombudsman, you can call 1-800-MEDICARE (1-800-633-4227), TTY users should call 1-877-486-2048. Once you reach the representative, ask them to send your inquiry to the MBO. According to the Medicare.gov website, you can also provide feedback to the Ombudsman to help improve your experiences.
You might also contact your Medicare Beneficiary Ombudsman locally through your state’s government website. Your local State Health Insurance Assistance Program (SHIP) can be viewed on

this website.

The

CMS website

also has a page dedicated to resources regarding how to contact a Medicare Beneficiary Ombudsman.
If you want to email an Ombudsman directly, you can at the following email: Medicareombudsman@cms.hhs.gov

What to expect when contacting a Medicare Ombudsman

When contacting a Medicare Ombudsman, beneficiaries can expect to receive information, support, and assistance with their issues or complaints related to Medicare. Here is an overview of what beneficiaries can expect when contacting a Medicare Ombudsman:
Initial Contact: When you first contact the Medicare Ombudsman, you might speak with an intake specialist who will listen to your concerns and provide you with information and support. They may ask you questions to better understand your issue or complaint and gather any necessary information to help you.
Case Review: Once your case has been assigned to a Medicare Ombudsman, they will review your case and work with you to develop a plan for resolving your issue or complaint. They will explain the steps involved in the process and provide you with information about your rights and protections under Medicare.
Investigation and Advocacy: The Medicare Ombudsman will investigate your issue or complaint, gather any necessary information, and work with you to develop a plan for resolving the issue. They will advocate on your behalf and work with Medicare and healthcare providers to find a resolution that is fair and equitable.
Follow-Up: The Medicare Ombudsman will keep you informed of the progress of your case and any updates or developments. They will also follow up with you to ensure that the issue has been resolved to your satisfaction.
The process and timeline for resolving issues or complaints may vary depending on the nature of the issue and the complexity of the case. Some cases may be resolved quickly, while others may require more investigation and advocacy. The Medicare Ombudsman will work with you to set realistic expectations and keep you informed throughout the process. They will also provide you with information about the Medicare complaint and appeal process if necessary.

Tips for preparing to contact Medicare Ombudsman

Preparing to contact the Medicare Ombudsman can help ensure that you make the most of your interaction and get the support and assistance you need. Here are some tips for preparing to contact the Medicare Ombudsman:
  1. Gather information: Before contacting the Medicare Ombudsman, gather relevant information about your issue, such as medical bills or correspondence from your healthcare providers. Having this information on hand can help the Ombudsman better understand your situation and advocate on your behalf.
  2. Be proactive: The Medicare Ombudsman is there to assist you, but it's important to be proactive in your approach. No one will be a better advocate for you than yourself. If you have questions or concerns about the process or timeline, ask for clarification. If you think there may be additional information that could be helpful, offer to provide it. Being proactive can help ensure that your issue or complaint is resolved as quickly and efficiently as possible.
  3. Take notes: Keep a record of all correspondence and interactions with the Medicare Ombudsman, including dates, times, and the names of the people you speak with. This can help you keep track of the progress of your case and provide a reference in case you need to follow up.
  4. Follow up: After your interaction with the Medicare Ombudsman, follow up if necessary. If you have additional questions or concerns, don't hesitate to contact them again. Keep in mind that the Ombudsman is there to assist you, and they want to ensure that your issue or complaint is resolved to your satisfaction.
By preparing in advance and being proactive in your approach, you can make the most of your interaction with the Medicare Ombudsman and get the support and assistance you need.

Conclusion

A Medicare Beneficiary Ombudsman can be a valuable resource for Medicare beneficiaries who feel their rights have been violated or have issues with their Medicare coverage or services. The Ombudsman serves as an independent advocate and can assist with filing complaints and appeals related to Medicare services and coverage. If you need to contact your local Medicare Beneficiary Ombudsman, you can call 1-800-MEDICARE, TTY users should call 1-877-486-2048 or contact them through your state government website.
If you need assistance finding the right Medicare plan or have any questions, please call

Fair Square

at 888-376-2028 to speak with a licensed agent today.

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