Appeals and Grievances Process

For Healthcare

Challenges Faced:

• Highly regulated, scrutinized and monitored process with significant fines and penalties for non-compliance
• Need to commit to the consistency, accuracy, and standardization requirements
• Difficult  and time-consuming process of retrieving case information from disparate sources
• Providing status to appellants on their appeals /grievances in real time
• Each line of business (Claims/Pharmacy/Core Appeals/Grievance) has its own different mandated Service Level Agreement (SLA) and corresponding turnaround time (TAT)
• Need to adapt to dynamic process changes and regulatory requirements
• Inefficient, manual complaint processing with no provision for automated alerts, notifications and escalations to managers about the cases with expired due dates

Newgen’s solution for appeals and grievances process automation enables payers to resolve member requests within specified timelines, reduce operational costs, enhance operational efficiency and demonstrate compliance – ultimately leading to improved levels of member satisfaction and higher profit margins.

Solution Highlights

• Automated  and Streamlined Workflow: Elimination of data entry errors and process compromises due to reduced manual handoffs; Process standardization and consistency across intake channels, result in improved quality and timeliness of decision making
• Rules Engine: Automatic due date calculation, validations for doing the work right the first time, escalation and email-based alerts, exceptions management for case processing, automated classification and prioritization of case
• Content Management: Supporting documents such as signature forms, physician reports and other material information automatically detected upon arrival and attached to the corresponding case file; Reduced cases of misplaced and lost documents
• Case Prioritization: Based on compliance due date, expedited request and other set of configurable variables
• Monitoring Dashboard: Enables end-to-end visibility into the process, and generates real-time reports for allowing management can gauge efficiency
• Audit History: The system keeps track of all changes made to any data field pertaining to a case along with user, date and, time; Provision for Quality Checks and Sampling
• Auto Routing: Immediate routing and redirection of files between departments resulting in reduced cases of missing compliance timelines, lost files and hence improved member/provider satisfaction
• Auto Letter Generation: Automatically generates faxes and letters to members and providers; all correspondence is automatically stored along with the case file with details about the date and time the correspondence

Benefits

• Improve operational efficiencies- A rules-based workflow ensures that the process is conducted consistently and in a streamlined manner with minimal human intervention. Automated workflow results in drastically reduced TATs.
• Cut operational costs - Costs associated with physical handling, routing and storage of documents are eliminated. Moreover consistent compliance with regulations helps mitigate penalties and fines.
• Meet regulatory and service level compliance standards- The monitoring dashboard allows for real-time visibility of the process by management and promotes a proactive approach to case handling and compliance deadlines.
• Ensure member and provider satisfaction- Faster resolution of requests and improved quality of service leads to enhanced member loyalty and reduced provider attrition.