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 superior experiences, in addition to getting their bare minimum health and safety concerns addressed. No organization wants to deal with complaints. But, if complaints do occur, an efficient and friendly process is required to develop the much-needed trust among members, providers, healthcare payers, and regulators. Easier said than done, most appeals and grievances process, unfortunately, hurt instead. To address the core issues, you first need to find out the key reasons impacting your processes.

Understand the Actual Reasons for Why Your Process Hurts

Here’s a quick run-down of 5 reasons due to which appeals & grievances process hurts and amplifies in the absence of the right technological support:

  • Siloed functions & systems – The process cannot function in isolation. It demands multiple systems and functions to work together, from the time a complaint, appeal, or grievance is raised till completion. However, most systems and functions work in silos, resulting in unnecessary delays.
  • Physical documentation – The 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 efforts for performing data entries, work hand-offs and reconciliation. As a result, the available systems, with limitations, do not tie well into the process. This leads to costly hand-off delays and errors.
  • Untraceable actions – For the process to function in a seamless manner, it’s important to have the capability to track information, concerned history, and past actions. However, a majority of processes are ill-equipped to do this. This compels caseworkers to scramble for the required information.
  • Rigid processes – Agility is a pre-requisite to make changes in conjunction with the process and attain the required level of efficiencies. However, rigidity in the existing systems and processes makes it difficult to make any change.

The Need of the Hour – The Process Optimization

Take the automation way; optimize the process to break the silos through process orchestration and witness improved outcomes including:

  • 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 a variety of incoming cases
  • Automated workflows and productive workers
  • Safe documents in a digital vault with 100% audited authorization

Conclusion Drawn

A happy member is proof of the process thriving! Thus, you must channelize 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 will help you understand how you can overcome process inefficiencies and exceed members’ expectations.


March 21, 2018 0 Comments

With 12+ years of experience in US Healthcare industry, Prashant holds his expertise in Product Development, Product Marketing, Go-to-market strategies, Provider contracting, A&G, Mobile Enrollment, and Credentialing.