Five Reasons Your Appeals & Grievances Process Hurts

Why Health Plans Must Modernize CAG to Protect Satisfaction and Compliance?

Every health plan wants satisfied members and regulators who trust their service delivery. But when issues arise, an efficient, structured, and supportive appeals and grievances (CAG) process becomes critical. Unfortunately, many health plans still struggle with operational challenges that delay issue resolution, create unnecessary costs, and put both compliance and reputation at risk.

This eBook sheds light on why the CAG process is breaking down in many organizations and why modernization is essential to ensure fairness, protect ratings, and strengthen overall experience.

The High Stakes of Appeals and Grievances

Appeals and grievances extend far beyond customer service requests. They influence:

• Member trust and retention
• Provider relationships
• Regulatory satisfaction
• Star ratings and reimbursements

Healthcare payers continue to see a growing volume of appeals, escalations, and costly rework. Even when a plan wins most disputes, the operational burden is heavy.

One example cited in this document highlights that more than two-thirds of Medicare reconsiderations were upheld, yet still carried over one hundred million dollars in contested claim value. Every appeal processed demands time and resources that could have been managed more efficiently earlier in the journey.

This is only the surface. For every formal appeal, there may be dozens of informal complaints that require resolution, documentation, and follow-through.

Why Today’s CAG Demands Outpace Capability?

Multiple dynamic pressures are reshaping expectations:

• Members are more informed and vocal about their rights
• Healthcare services are becoming more consumer-driven
• Regulatory oversight continues to intensify
• Customer experience is now tied to compliance performance

Federal evaluation programs consider appeals and grievances as a major assessment category, making the operational maturity of CAG processes directly tied to plan success.

Most plans know they need improvement. But knowing is not the same as being structurally ready to act.

The Hidden Reasons Your CAG Process Hurts

The eBook identifies five core failures holding CAG back:

1. Siloed Functions and Technology

When workflows span fragmented systems:

• Information is duplicated or lost
• Hand-offs slow down turnaround time
• Administrative cost spikes
• Audit readiness becomes nearly impossible

Teams must rely on emails, spreadsheets, and manual cross-checks. With no unified case record, tracking decisions and actions becomes a major burden.

2. Heavy Dependence on Physical Documentation

Despite digital advances, CAG remains paper-intensive. Processing physical documents causes:

• Higher effort for storage, retrieval, and shipment
• Increased rework when documents are inaccurate
• Version control confusion
• Longer completion cycles
• Greater risk of critical data loss

Any procedural variation across states multiplies the complexity and administrative load.

3. Manual Processes Cause Errors and Delays

Manual reconciliation and data entry create:

• Repeated exception handling
• Increased compliance risks
• Delayed communications with members and providers
• Workforce burnout from avoidable workload

Critical checks like duplicate detection or historical record review are often skipped due to time or system constraints.

4. Lack of Traceability and Visibility

Teams struggle to locate:

• Prior decisions
• All supporting documents
• Member and provider communications
• Case history data

This undermines fairness and accountability. Under regulatory review, lack of traceability creates exposure and reputational harm.

5. Rigid and Inflexible Systems

Dynamic regulations require systems that adapt at speed. But legacy platforms:

• Restrict process changes
• Increase risk of outdated responses
• Constrain staff into inefficient methods
• Slow down CAG improvements that matter to members

Member expectations evolve quickly. Legacy CAG systems do not.

The Real Impact on Satisfaction and Compliance

When CAG processes lag:

• Members suffer slow and confusing responses
• Regulators escalate oversight
• Star ratings decline
• Operational cost surges from duplicated work
• Workforce frustration leads to turnover

This prevents health plans from delivering an experience centered around empathy, fairness, and timely resolution.

The Path Forward: Modernizing CAG End-to-End

To overcome these issues, health plans must:

• Digitize intake and document handling across all channels
• Automate case routing and validations based on business rules
• Provide unified case views for complete visibility
• Enable secure and timely interactions with members
• Invest in intelligent audit logging and compliance guardrails
• Adopt flexible tools that evolve with regulation

Better systems give teams the ability to focus on service, not struggle with administration.

A Platform-Enabled Strategy

The eBook encourages health plans to adopt a unified solution that supports:

• Configurable workflows
• Smart documentation capture
• Real-time tracking and communication
• Replicable best practices across states
• Rapid enhancements without coding hurdles

When CAG becomes intelligent and responsive, health plans reduce disputes earlier in the cycle and resolve legitimate ones faster.

How Newgen Supports CAG Excellence?

Newgen enables automated and governed complaints, appeals, and grievances workflows with a secure platform that unifies content, processes, and communication. Teams get a full 360-degree case visibility, faster hand-offs, and digital support that keeps members updated and regulators confident in the plan’s actions.

Make Members Feel Heard, Valued, and Protected

Member happiness is more than a goal — it is proof that the service model works. Health plans that modernize CAG create a virtuous cycle: stronger trust, improved ratings, reduced disputes, and lower operational stress.

This transformation ensures that the voice of every member is respected, addressed, and acted upon with fairness and transparency. The sooner health plans embrace intelligent CAG modernization, the sooner they become recognized for delivering not only healthcare coverage, but genuine care.