Digital Themes

Appeals and Grievances

What is appeals and grievances in healthcare?

Appeals and grievances are the complaints and escalations associated with a patient’s care. If a patient is in any way unsatisfied with the service that they received, be it the cost or the care itself, then patients are entitled to file a grievance, and if they are unhappy with the resolution of the grievance, they can file an appeal. This is often a process that takes a long time to fully resolve, and it can be challenging for healthcare providers to stay on top of all the associated tasks involved. For this reason, many healthcare payers are choosing to utilize digital tools and solutions to manage their appeals and grievances.

The software for appeals and grievances generally allows for customizations, so organizations that have an existing manual process can customize their digital solution to match. This means that each organization can select who is the first point of contact for each claim, as well as who it goes to next, and what data is collected at each step. After initial set up, this customized program will follow the same general flow, but will allow for more detailed and verified data collection, as well as speeding up the overall process. Additionally, these processes incorporate automatic checks for errors, which can be costly and time consuming.

Oftentimes, the back-office functions involved in managing appeals and grievances can be very time consuming. It requires information from across the healthcare payers system, and data fragmentation can often be a difficult hurdle to address when moving between siloed departments and getting information to and from people in different roles. Digital appeals and grievances software typically utilizes data flows to accelerate decisioning and get the appropriate information to the correct people. This process is usually automated, meaning that as soon as one person finishes their part, it is automatically forwarded to whoever has the next task. This means that it can move from triager, to case owner, to the registered nurse, to the medical director without the need for the individuals to manually forward the information. Many systems are also able to automate outbound emails, such as acknowledgments and resolution letters. This speeds up the process and ensures regulatory compliance.

Appeals and grievances software is most useful when it is part of a larger digital healthcare payer solution. For example, when a complete cloud solution is utilized for every step of the healthcare process, organizations can automatically aggregate all patient data, from vitals to billing to prescriptions. This allows for easy access to any data needed as part of an appeal or grievance process. Many such systems include the use of artificial intelligence to verify information, or to make recommendations around next steps and what other data could be included. Cloud solutions also frequently include integrated regulatory guidelines, meaning that healthcare payers can ensure that they are in compliance with all laws and regulations at each step of the process.


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Digital appeals and grievances software and solutions can benefit healthcare organizations by:

  • Decreasing manual processes and wait times: Rather than having to be manually delivered across the organization, automated solutions allow for quick transmission of data at each step of the process.
  • Enhanced data collection and processing: Cloud services allow organizations quick access to relevant data, without the need to search through multiple locations to find it. Many cloud solutions allow for centralized and secure data storage.
  • Enriched cases and increased member satisfaction: Collected data can easily be communicated to enhance communications around appeals and grievances. Additionally, by speeding up the overall process, employees can have more time to spend on individual cases to ensure the information is as thorough as possible. Furthermore, members can expect a quick and accurate response from these systems and procedures.
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