As the holiday season graces us with its warm embrace and the aroma of Thanksgiving feasts fills the air, let’s go through a heartwarming tale of a member—Molly.

A Thanksgiving Tale: Molly’s Gratitude

Name: Molly
Age: Early 40s
Family: A dear wife and a mother to two adorable children
Profession: 24*7 mother with a 9-5 career

Seated at her dining table, Molly was encircled by her family, a nice Thanksgiving feast adorning the setting. The aroma of roasted turkey and pumpkin pie filled the air, but Molly’s thoughts were occupied with something unusual that day. As she was about to savor the delicacies, she couldn’t help but reflect on how thankful she was for her health payer.

The year had been full of challenges for Molly regarding her health and well-being, but her health plan had been there every step of the way. She looked around at her family, the smiling faces of her children and the happy gaze of her husband, and she couldn’t help but smile. Her health and well-being were the foundation that allowed her to enjoy these precious moments.

As Molly looked around at her family enjoying the Thanksgiving meal, she couldn’t help but feel grateful not only for their presence but for the health plan that had been with them every step of the way providing her with timely responses to her appeals and grievances.

Molly’s tale is a striking reminder of the power of a dependable health plan, underscoring how a member-centric approach can truly change lives.

Be the Health Plan Your Members Deserve

Dear Health Plans

I’m sure you’d aspire to mirror Molly’s experience.! And, guess what? You can make it happen! However, achieving such member-centricity requires more than words; it demands genuine commitment. It’s about forging a culture of trust and responsiveness.

And, what better time to embark on this transformative journey than the Thanksgiving season?

As we immerse ourselves in the Thanksgiving spirit, let’s explore how you can express gratitude to its members by overcoming the obstacles that often obstruct seamless and efficient appeals and grievances processes.

But how, you might be wondering?

First and foremost, it’s important for you to reevaluate your appeals and grievances processes. This calls for a reality check. Ask yourself some of the critical questions, including:

  • Can your processes handle complaints, appeals, and grievances from multiple channels on a day-to-day basis?
  • Are your departments reliant on multiple systems to resolve cases, resulting in delays and inefficiencies?
  • Is case tracking a challenge for your case workers, leading to slower resolutions?
  • Are your caseworkers providing timely resolutions to members’ appeals?

Identifying Core Roadblocks

Subsequently, you need to identify the roadblocks obstructing your path while managing appeals and grievances. Some of them can be:

Siloed Functions & Systems: Your different departments and systems must work together seamlessly from the moment a case starts until it’s resolved. Delays in entering, validating, and processing cases can lead to inefficiency and errors

Physical Documentation: Dealing with an abundance of paperwork incurs extra costs, from printing, dispatch to collecting, and storing all those physical documents. It can slow down your processes by a significant margin

Manual Processes: Excessive reliance on manual work, including data entry and reconciliation, can introduce errors and exceptions that are best avoided

Untraceable Actions: Your caseworkers must be able to efficiently track and monitor each case. If your systems fall short in this regard, case workers end up scrambling to gather information for reports and reviews

Breaking Down Barriers for Frictionless Services to Members

Now, to provide your members with exceptional services, you’ll need the right and robust processes. For instance, imagine a member files a complaint online but then switches to another channel for some reason. Your process should be user-friendly enough to let them continue seamlessly on that new channel. To make this a reality, here are some key considerations you should look for in an ideal appeals and grievances solution:

Automated Intake and Triage: Let members initiate cases through different channels while enabling caseworkers to manage them all from one place. Collaboration with both internal and external partners should be seamless and effortless

CMS Compliance: Get a solution that gives clear insights into your processes with detailed reports and dashboards, ensuring you stay on top of regulatory requirements

Auto-alerts & Notifications: Ensure your solution keeps case managers in loop with alerts and notifications, preventing duplicate cases and ensuring timely resolutions

Secure Archival of Documents: Make sure your solution offers a central place to store all your case-related documents. This will make it easy for your users to access information and retrieve important contracts in a timely manner

Timely Resolutions: Make sure your caseworkers solve problems for members quickly, and  no appeal breaks the rules or go out of compliance
Advanced Case Management Capabilities: Equip your caseworkers with the tools to be flexible and adapt resource management to cater to your business needs

Express Gratitude to Your Members This Thanksgiving

As the holiday season draws near and Thanksgiving awaits, streamline your appeals and grievances process and make your members smile. Offering them quick and precise resolutions is the most heartfelt way to express your gratitude!

Happy Thanksgiving!

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