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How MA plans can get ahead of the curve on appeals and grievances

How MA plans can improve management of appeals and grievances

3 min read


Appeals and grievances


This post is sponsored by Convey Health Solutions.

Many payers are behind the curve on management of appeals and grievances, struggling with outdated technology and procedures. Some are still handling filings manually with spreadsheets. Others use technology designed by software developers without the input of regulatory and health care experts.

Antiquated methods lead to needless hours spent compiling data and trying to verify which regulations apply and how to comply with them. The repercussions can include missed deadlines, hefty fines and angry customers.

Plans that are ahead of the pack use automated processes to speed resolution and to lower the risk of non-compliance from user errors. These technologies preserve all details and updates for a grievance in a digital format that can easily be searched. This creates an audit trail and helps payers more quickly determine the status and root cause of a grievance. More robust reporting and analytics helps plans turn this data into process improvements that lead to reductions in grievances and higher member satisfaction. And for members that do have grievances, plans with high-quality automated processes resolve cases timely and appropriately, reducing member dissatisfaction.

Unfortunately, for those still struggling with outdated systems, there are a variety of risks beyond these missed opportunities. The CMS takes violations of appeals and grievance rules seriously, and penalties can be harsh.

Consequences of noncompliance

One Medicare Advantage carrier was fined more than $3.1 million in 2015 for violations that included failure to comply with organization/coverage determinations, appeals and grievances.

More recently the CMS fined a Part D plan more than $1.3 million for misclassifying coverage determination requests as grievances or customer service inquiries, among other violations.

Plans are at risk for citations for a variety of issues that purpose-built automated systems can avoid. These include:

  • misclassification of appeals and grievances
  • miscalculated due dates
  • failure to fill out required fields on forms
  • lack of adequate rationale in denial letters
  • inadequate records tracking and maintenance

And along with these citations come dissatisfied members who are more likely to switch plans.

A better way to handle grievances

Modern technology helps keep plans out of trouble with regulators and members alike. An expert-designed MA/Part D appeals and grievance resolution system ensures regulatory compliance and improves efficiency. It increases the likelihood that appeals and grievances will be properly classified and resolved quickly and correctly, avoiding member complaints, dings to Star ratings, and CMS fines and penalties.

Integrated, automated appeals and grievance technology like Miramar:Resolve from Convey Health Solutions can also help payers see the entire story of an appeal or grievance and discover the root cause of the problem. At the same time, it creates an audit trail, enabling full access and investigation of case histories.

The technology aids case managers, as smart wizards, scripting, automated referrals and role-based securities streamline processes and guide them through complex CMS requirements, further reducing the chance of errors.

Resolution systems like Miramar:Resolve can be standalone or integrated with enrollment and billing platforms for a faster, more simplified experience for both customers and case managers.

Improving complaint resolution efficiency improves the customer experience while saving time and money for the plan. MA and Part D plans that focus on member health while boosting back-office efficiency will stand out in a crowded market because of their ability to provide the best experience for their members at all stages of the claims process.

Convey Health Solutions focuses on building specific technologies and services that can uniquely meet the needs of government-sponsored health plans. Convey provides member management solutions for the rapidly changing health care world. Learn more.