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Simplify Appeals & Grievances Processing

with Virtusa's automated AI-based solution

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Healthcare payers are under constant pressure to manage their appeals and grievances (A&G) processing amid unpredictable workloads and disintegrated data flows across the enterprise.

Virtusa’s A&G solution offers simplified case management and automated task handling, coupled with industry-standard classifications, that ensure accelerated case resolution. The solution provides intuitive and guided workflows to help users navigate through the complex case life cycle. With machine learning at its core for decision making, the solution will enable medical directors to make smarter decisions.

Multi-level appeal escalation (to IRE, ALJ, MAC, and Judicial Review) is supported for adherence to Medicare Part C statutory requirements. Overall, Virtusa’s A&G solution helps payer organizations to effectively manage their appeals and grievances business and thereby achieve high customer satisfaction and better adherence to regulatory guidelines.

Intelligent Digitization of Appeals & Grievances

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Accelerated decisioning

The solution segments the complex A&G process into concise, contained, and clearly defined activities routed selectively to the appropriate teams – Triager, Case Owner, Registered Nurse and Medical Director.

Targeted critical data

Display of relevant data up-front to support user decisions – enrich complaint case with authorization or claims data based on pre-service or post-service appeals.

Dynamic SLA Management

Ease of managing State specific and Line of business specific Service Levels mandated by regulatory guidelines.

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Frequently Asked Questions
What is Virtusa’s Appeals & Grievances (A&G) processing solution?

Virtusa’s A&G is an AI-powered solution built with six interconnected modules to simplify case management and automate task handling. With machine learning (ML) at its core, the solution provides intuitive and guided workflows to help users navigate the complex case life cycle.

Virtusa’s A&G solution helps accelerate case resolution with AI-assisted clinical review for real-time recommendations to doctors and nurses to enable accurate decision-making for pre and post-service appeals. 

Virtusa’s A&G has six interconnected modules that enable an appeal or grievance case to get processed end-to-end. A module is selected based on the business need and ROI. The modules include:

  • Omni-channel complaint intake and triage
  • Research and administrative review
  • AI-assisted clinical review
  • Case support and resolution
  • External entity review
  • Correspondence management and reporting

Virtusa’s A&G helps businesses with caseload management and stay within regulatory timelines when filing and processing an appeals or grievance case. Backed by AI-based algorithms, the solution eases caseload, automates task handling, and streamlines complex business rules with the following workflow:

  • Member/provider calls
  • Appeals case triage
  • Automated case routing
  • Case processing
  • Registered nurse clinical review
  • Medical director clinical review
  • Case resolution

 

With Virtusa’s A&G healthcare payers:

  • Accelerate decision making
  • Target critical data
  • Automate repeatable tasks
  • Improve user experience
  • Enhance service levels

Virtusa’s A&G helps users navigate the complex case life cycle, achieve high customer satisfaction, and ensure better adherence to regulatory guidelines with the following advanced features:

  • Smart case management for higher visibility
  • Predictive models for better decisions
  • SLA management that is easily configurable
  • Integrated repository for easy access to case information
  • Automated outbound correspondence for high efficiency
  • Support for claims and pre-authorizations 

Virtusa’s A&G is HIPAA compliant with security standards and has the highest security rating with HITRUST CSF certification. The solution’s IT infrastructure has advanced security controls to protect sensitive personal data and is compliant with all mandated regulations. 

Virtusa’s A&G processing solution uses AI-based real-time recommendations for simplified case management and automated workflows. A clinical review by a registered nurse and medical director is administered where cases are smartly routed based on the skills of the registered nurse. Decision-making capabilities are simplified by AI-assisted algorithms for medical directors when looking at pre-and post-service appeals. The registered nurse has access to a portal with a dashboard for a holistic view of the pending case.

Virtusa’s A&G dashboard gives the registered nurse a 360-degree view of the claim or authorization available for verification. A prompt decision at a line-item level is initiated, allowing an AI-powered model to compare the current claim or authorization. It gives access to all previous ones in the database and recommends approval at the code level of the claim line procedure. The registered nurse reviews the case parameters and medical records aligned to the appeal. The system then allows the registered nurse to make a swift decision backed by insights derived from historical data. 

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