What is a Health Care Ombudsman?

An individual who investigates complaints by District consumers regarding health care issues against their health plan or provider.

A neutral mediator in dispute resolution, with the ability to investigate and make recommendations – without authority to make or reverse a decision.

An individual who will conduct their work objectively and without influence from representatives and Administrators of the DC Government.

What is the Office of Health Care Ombudsman and Bill of Rights?

The Office of Health Care Ombudsman and Bill of Rights was established by the Council of the District of Columbia to assist individuals insured by health plans in the District of Columbia and to assist uninsured District of Columbia consumers.

What Does the Office of Health Care Ombudsman and Bill of Rights Do?

• Assist consumers in resolving problems concerning health care bills, health coverage and access to health care by referring consumers to appropriate regulatory agencies when their problems are within an agency’s jurisdiction, guiding consumers through existing complaint processes, and assisting consumers in informally resolving problems through discussions with their health benefits plans;
• Assist consumers in understanding their rights and responsibilities as  health benefits plan members, including appeal processes and how to use them, and how to access appropriate medical information;
• Educate consumers about health benefits plans, managed care health plans, and their health benefits plan options, or other health care options available for uninsured consumers;
• Comment on behalf of consumers on related health care policy legislation and regulations in the District of Columbia;
• Help uninsured District of Columbia residents access Medicaid or other health care options;
• Identify, investigate, and help resolve complaints on behalf of consumers with the filing, pursuit, and resolution of formal and informal complaints and appeals through existing processes, including internal reviews conducted by health benefits plans, grievance and appeals processed, fair hearings available to Medicaid consumers, external reviews before independent review organizations and any other administrative appeals that may be available under the District of Columbia or federal law;
• Refer consumers, when appropriate, to other existing organizations for assistance and work jointly with other consumer organizations, as appropriate;
• Work with health care providers to develop working relationships that will enhance coordination and referrals;
• Make appropriate referrals to various appropriate agencies and organizations; and
• Provide information to the public, government agencies, the Council of the District of Columbia and other regarding problems and concerns of consumers and make recommendations for resolving those problem and concerns.