success story

Unified Appeals & Grievances (A&G) platform boosts user satisfaction and reduces costs

Creating scalable processes with strong reporting

Virtusa helped a nationwide U.S. healthcare payer simplify an appeals and grievances (A&G) system that had grown slow and complicated over many years. Manual processes contributed to inaccuracies and delays.

We used the Pega platform to introduce automation, centralize operations, bulk up reporting capabilities, and improve user satisfaction. 

The challenge

Bulky and inefficient legacy A&G systems needed consolidation

Resolving appeals and grievances (A&G) claims had become cumbersome and was affecting the healthcare payer’s bottom line. Multiple A&G systems for members, combined with dozens of third-party systems, yielded bulky, inefficient processes that were error-prone and difficult for all parties. 

Among the key issues: 

  • Isolated data sources and manual processes made A&G settlements time-consuming and labor-intensive.  
  • Legal workflows in these complex enterprise systems were riddled with constraints and restrictions. 
  • Disconnected systems and offline processes contributed to slow claims processing.  
  • Traceability, trending, and reporting was lacking across the board. 
  • Automation was inconsistent and inadequate in areas such as assigning tasks and managing the intake inventory.
The solution

Migration to common A&G platform with strong automation and reporting

By partnering with Virtusa, the company consolidated disparate processes, automated manual methodologies, implemented strong reporting, and migrated to a unified, centralized platform.

Virtusa designed a solution promoting uniform and equitable responses to appeals & grievances claims. We helped the payer migrate the scattered and siloed legacy A&G systems to a common platform with these primary components: 

  • Intake: Virtusa crafted an enterprise intake process that accepts A&G claims in four formats: verbal, written, fax, and web. Case processing uses a well-defined SLA in the Pega decision algorithm. Automated intake includes digital agents that do not require human interactions.
  • Data and reporting: We made data access seamless with an internal SOA layer that interacts with membership source systems. Custom-built data structure maintains online traction data. The reporting data layer uses regular automated BIX extracts.
  • Automation: We fine-tuned an automated decision model with Pega robotic process automation (RPA) on commercial lines of business. 
  • Document Repository Integration: Integrated existing document repository to add/ attach documents to the cases. 
  • Artificial Intelligence: We populated required fields automatically and the solution also checks for duplicate/similar types of previously closed cases and gives case insights for quick resolutions.
Unified Appeals & Grievances (A&G) platform boosts user satisfaction and reduces costs
The benefit

Increased user satisfaction, one centralized platform, streamlined automation, and reporting

These improvements helped the company transform its A&G processes and methodologies. 

By utilizing one common platform that centralizes all channels, the company can support eight-plus A&G source systems and 45-plus external, third-party systems. Among the gains: 

  • Employees have higher job satisfaction and less on-the-job frustration. Flawless workflows enable robust case management.
  • An inbuilt content management system reduces cost and accelerates data retrieval. The enterprise application design scales to support a large user base.  
  • Automated member communications generate letters and notifications within Pega, improving accuracy, consistency, and member satisfaction. 
  • Powerful reporting tools help the company track progress toward goals. 
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