Industry Expert Q&A - What to Look for in an Appeals & Grievances Technology Solution

Whether you are part of a Medicare, Medicaid, Marketplace or Commercial Health Plan, you know that effective oversight and management of Appeals & Grievances (A&G) can be a laborious and time-consuming process. Despite recent innovations, many health plans still rely on homegrown or manual A&G processes that often result in data integrity issues, unpredictable results, and non-compliance penalties. 

Regulatory compliance, processes, and technology must all be aligned to create a best-in-class A&G department and product. But how does a health plan get there? We recently spoke with Craig Giangregorio, Senior Vice President of Healthcare Solutions at Inovaare, and asked him what features and components are most important for a health plan to consider when choosing an A&G technology platform. 

Q: What should a plan look for in an A&G technology solution to ensure that a department is reaching their highest levels of compliance? 

CG: The compliance piece of the puzzle is so important. Health plans must ensure their compliance procedures are not only updated but also ready for audit. Quick turnaround of consistently compliant resolutions is not only required to satisfy regulatory requirements, but it also provides a significant competitive edge over other health plans.  

The technology should, above all else, include the rules and logic necessary to ensure the A&G department stays compliant on every case. An A&G solution that can simplify regulatory reporting and processes through robust intelligent automation, real-time alerts and configurable workflow rules is the best bet for achieving penalty-free regulatory compliance. That means proactive, compliance-driven automation is built right into the workflow process, for a seamless and member-centric experience every time. 

Q:  What are some of the key deliverables an A&G solution should offer when it comes to regulatory reporting? 

CG:  Plans are required to report on outcomes and are subject to audit on a periodic basis by CMS, Medicaid, and NCQA. The best Appeals & Grievances technology providers will help plans to capture data and document it in a way that mitigates the risk of audit penalties, which can become financially catastrophic to a plan should they encounter multiple deficiencies.  

Good reporting takes preparation to get right. The inputs, and how they are managed, are critical to ensuring the output is correct. A good A&G technology solution will enable reporting to be configurable, real-time and proactive, and also available at the touch of a button. When the technology is embedded with the latest CMS protocols and customizable, it is that much easier and seamless for department leaders.  

Q: What business processes could be improved within the A&G department through an automated A&G solution? 

CG: A&G workflow processes are highly regulated and often very complicated. Stringent record-keeping and an eye for detail are imperative to the success of a program. A system that can seamlessly automate these A&G processes is critical for empowering A&G professionals to operate efficiently, without having to rely on IT support.  

If there ever was a place in an Appeals & Grievances system that should have compliance embedded, it is the A&G workflows. Health plans won’t have a legitimate case in the eyes of CMS without a valid requestor and requestor document per CMS regulations. Health plans also need to conduct outreaches at the appropriate times using accepted methods to chase down a valid appointment of representative (AOR), should one exist for the given episode. 

Each field and every step in a workflow should be relevant, to ensure both compliance and efficiency. Common to all workflows, two outputs should be prioritized: comprehensive, accurate documentation of all cases; and compliance-based workflows to meet regulatory requirements. 

“As a leader over the A&G Department, I am primarily focused on compliance adherence and improving operational efficiency. When selecting a vendor to deliver an A&G Platform, I am expecting a partner who is a subject matter expert in compliance and who leverages technology to automate our processes.”   

- Director, Appeals & Grievances Department

Q: How does an A&G solution enable cross-collaboration between health plan departments as well as timely communication between the plan and its members? 

CG: The investigation and resolution process for any appeal or grievance may require additional departments’ involvement. For this reason, collaboration between departments needs to be seamless and pain-free. An effective A&G technology solution can create 360-degree member views and provide end-to-end visibility for efficient issue resolutions.  

This comprehensive snapshot incorporates all necessary information in one view that is visible across disciplines. Communication across departments should ideally be automated and self-contained within the member view and the episode. Tasking and activity completion should readily be available to the users so that any stakeholder can view their assignment with the appeal or grievance. Additionally, a system should have a simplified but secure method of communicating externally should an independent review become necessary.  

The platform should integrate seamlessly with CM, UM, Quality, and other plan departments to enable all stakeholders to track appeals in progress alongside member demographics, enrollment, encounter data, and care planning information for a truly holistic member view of activity. The A&G technology solution should also resolve the disconnect that can happen between multiple legacy systems to effectively engage members at every touchpoint, in real-time.  

The key to improving the member experience is driving timely responses from departments and vendors through assignment of tasks to appropriate staff, tracking completion of each task, and automatically generating the appropriate correspondence and determination outcome to the member. 

Work with the Right A&G Technology Partner 

As you can see, there are many factors to consider when choosing an A&G technology solution. For this reason, it’s critical to partner with a vendor that has the compliance experience to guide you through each step of every process within an ever-changing regulatory environment.  

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