It’s amazing to see how far a simple ‘Thank you’ can go!

And, there couldn’t be a better day than Thanksgiving to express gratitude to members and providers. Thank you notes and visually appealing emails could be the anchors for expressing that gratitude, but this gesture is meaningful only when you’re truly a member-centric organization.

Many Health Plans say they are member-focused. Members are at the heart of their operating models. However, most of them fail to develop the much-needed trust among members. Plans’ operating models, how they organize and operate resources to execute their strategy – gets in the way.

So, being in the business of member experience, this Thanksgiving, set a high bar for simplicity, interactivity, and personalization while managing your members’ complaints, appeals and grievances.

In the highly regulated American Healthcare landscape, regardless of how well you’re managing your processes, you’ll receive complaints, appeals and grievances. And, when thousands of cases are registered each year, your members and providers will:

  • Call you
  • Show anger, in case of being neglected
  • Talk about unsatisfactory services, feeling you were unfair to them or took forever in offering them a resolution

So, how you manage these situations can Make or Break your organization!

Holding onto conventional ways, such as maintaining spreadsheets, word programs, manual data entries will consume valuable time, resources and increase business risk.

Now, the big question is ‘What’ should you do to earn your members’ trust?

To be operationally more efficient, do a reality check of complaint management processes. Question yourself –

  • Can my process handle complaints, appeals and grievances, coming from multiple channels, on a day-to-day basis?
  • Do my departments rely on multiple systems, such as claims, provider relations, pharmacy, and others to resolve cases?
  • If case tracking is a challenge for my case workers?

Heading to Real Roadblocks

There’s no shortcut to transparent and good quality services. And, the same goes for great processes too. Until an appeal or grievance is handled well, the process will hurt every day in terms of money, effort, and reputation. To overcome such business challenges, you must first know about real roadblocks:

  • Siloed Functions & SystemsMultiple systems and functions must interact with one another from case initiation until a resolution letter is handed/issued. Longer time to enter, validate, and process cases increase inefficiency and result in erroneous services
  • Physical DocumentationNeedless to say, the overall process is document-heavy. Hence, it results in operational overheads associated with processing due to printing, dispatch, collection, and storage of physical documents
  • Manual Processes-  Heavy dependency on manual efforts, involving data entries and reconciliation, leads to undesirable errors and exceptions
  • Untraceable ActionsCaseworkers have to track historical details and past actions of cases. However, ill-equipped systems fail to work efficiently. Case managers end-up scrambling for information to report to authorities and independent review committees

Bidding Adieu to Process Barriers  

To offer delightful services to your members, you would first need the right process support. For instance – A member files a complaint via an online portal. For an unsolicited reason, he moves to a different channel to complete his/her interaction. In such a case, your process must be user-friendly for your customer to resume the process on another channel in a seamless way. To make this happen, we’ve rounded-off some critical features of an ideal appeals and grievances solution that will enable you to get the right process support, drive compliant and member-centric processes:

  • Automated Intake and Triage of cases– Look for a solution that allows your members to initiate cases through multiple touch points. And, your caseworkers should be able to manage cases via a single unified platform. The interface should be user-friendly to collaborate with internal as well as external stakeholders
  • CMS Compliance- Leverage a solution that helps you gain visibility across processes with detailed reports and dashboards, while allowing your organization to be highly compliance-driven
  • Auto-alerts & Notification- To eliminate duplicate cases and ensure timely delivery of resolutions, the solution must send alerts and notifications to your case managers
  • Secure Archival of Documents– The solution must provide a centralized repository to archive all case-related documents. This will help you ensure easy access to information and retrieval of contracts
  • Advanced Case Management Capabilities- To bring flexibility into the process and enable caseworkers to manage resources and outcomes as per business requirements, advanced case management capabilities will come to the rescue

So, as the festive season sets in and turkey takes center stage, ensure your members are heard, understood, respected, and are delivered quick & accurate resolutions.

Happy Thanksgiving!