Member complaints, appeals and grievances (A&G), are one of the most challenging and sensitive business responsibilities that payers must manage. In a highly regulated healthcare industry, providing timely resolutions to members by complying with CMS guidelines and business SLAs can be complex and manual-intensive effort.

In most scenarios, noncompliance to regulations and making quick and accurate decisions in appeals & grievances processing within a prescribed timeline leads to substantial financial penalties. The challenge is to navigate unpredictable workloads and disintegrated data flows across the enterprise.

This is where the payers need to quickly deploy intelligent, automated appeals and grievances process management for real-time insights and monitoring. Payers that are looking to make a differentiated impact must take the right step towards boosting quality scores and successful CMS star rating with digitized A&G processing. It helps to:

Augment business outcomes with an assured 8-12% boost in CMS star rating
Achieve 30% operational cost reduction and higher efficiency by shifting to an AI-enabled A&G platform
Enhance member and provider satisfaction by advancing to an intelligent appeals workflow

Understanding the challenges in the appeals and grievances business

The star rating impacts the customer’s decisions in a competitive marketplace and affects a member’s plan selection. Faster response times enabled by technology has a significant role to play in customer satisfaction. However, technological modernization is not applied uniformly across the enterprise. It leads to capability disparities, broken workflows, and data silos. Heterogeneous tech transformation, along with inefficient processing, leads to noncompliance.

The complexity for healthcare payers increases with multiple federal acts and rules, all of which directly impacts the A&G processing:

Audit & Appeals Fairness, Integrity and Reforms in Medicare Act (AFIRM)
Patient Protection and Affordable Care Act (ACA)
Health Insurance Portability and Accountability Act (HIPAA)
Social Security Act (SSA)

Business processes also need to provision for reviews by external entities. Payers need to track the event details and decisions at multiple levels. The A&G escalation matrix:

Appeal Level 1: Org reconsideration
Appeal Level 2: Independent review entity (IRE)
Appeal Level 3: Administrative law judge (ALJ) review
Appeal Level 4: Medicare appeals council (MAC)
Appeal Level 5: Judicial review by the federal district court

Performance indicators for A&G business

Process efficiency

Advanced interconnected workflows (HIPAA compliant)
Unified intake for complaints, appeals, grievances
Smart decision making with key ops dashboard and metrics
SLA-driven ability to track, route, and expedite cases

Resolution timeliness

Ability of real-time tracking of cases
Effective management of SLAs
Alerts and notifications against goals and deadlines
Template-driven uniform and timely outbound communication

Resolution accuracy

Upfront validation and duplicate check
Right data at right point of time for decision making
Decision recommendation based on historical records
Additional checkpoints on error-prone areas

Regulatory compliance

Detailed reporting and key metrics tracking functionality
Compliant processes to generate compliant reports
Regulatory audit readiness
Streamlined CMS universe reports

Efficient processes powered by state-of-the-art technologies
Built for agility, A&G solution powered with intelligent technologies enables healthcare organizations to quickly deploy and modify their appeals and grievances processes to address timeline, compliance, accuracy, and efficiency glitches.

Let us explore how to address the key challenges in your appeals and grievances processing and the pertinent solution for each paving the way for a futuristic integrated model:

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