A happy member and a satisfied regulator is every health plan’s wish. Members, these days, are well-informed and their tolerance level is lower. They expect enhanced overall experience, in addition to getting their bare minimum health and safety concerns addressed. No organization wants to deal with complaints. But, if complains do occur, an efficient and friendly process extends a helping hand in developing that much needed trust among members, providers, healthcare payers and regulators. Easier said than done, most appeals and grievances process, unfortunately, hurt instead. Thus, to address the core issues, it is essential for you to find out key reasons impacting your process.

Understand the Actual Reasons for Why Your Process Hurts

Here’s a quick run-down of various reasons due to which Appeals & Grievances process hurts and amplifies in the absence of the right technological support:

  • Siloed Functions & Systems – Appeals and Grievances process cannot function in isolation and demands multiple systems and functions to work together right from the initiation. The point of initiation is right from the time a complaint, or an appeal, or a grievance is raised till completion. Most systems and functions succumb and work in their silos, resulting in unnecessary delays.
  • Physical Documentation – Appeals and Grievances process has been conventionally accustomed to being document-heavy. Geographical distribution and variance at state level policies result in administrative overheads from redoing, reprinting, reprocessing and revalidating business policies and filed documents. Errors or inaccuracies, or misplaced documents result in further overhead and delays.
  • Manual Processes – Many Health Plans rely on manual effort of doing data entries, work hand-offs and reconciliation. As a result, available systems, with limitations, fail to blend into the process. This leads to costly hand-off delays, and undesirable errors.
  • Untraceable Actions – For Appeals & Grievances process to function in a flawless manner, it is important to have the ability to track down relevant information, concerned history and past actions. However, majority of processes are ill-equipped to do this. This compels Health Plans to scramble for the required information.
  • Rigid Processes – Agility is a pre-requisite to make changes in conjunction to the process and attain required level of efficiencies and for regulatory changes. However, rigidity in the existing systems and processes makes it difficult for Health Plans to make required set of changes.

Immediate need of the hour – Optimize your Appeals and Grievances Process

In the times of Digital members, you must accelerate your digital strategy and take the automation way. Optimize your Appeals and Grievances process to break the silos within your organization through process orchestration and witness improved outcomes such as:

  • Straight-through integration of backend systems with the front-end systems and processes, minimizing delays and wait times
  • Minimized manual hand-offs and higher collaboration with workflow automation
  • Consistent treatment across variety of incoming cases
  • Automated workflows and productive workers
  • Safe documents in digital vault with 100% audited authorization

Conclusion Drawn

A happy member is a proof of the process thriving, so it is for you to channelize your efforts in making your members smile.

To get detailed insights on the changing healthcare landscape, increasing member expectations, and tighter regulations, read the ebook here. The ebook guides you on how you can address the process challenges and make your members smile in the long run.