Appeals and Grievances – Would You Like A Shuttle Or An Uber?

Most of us have traveled at some point, either in our professional or personal lives. We have had to choose between taking the ride share SuperShuttle from the airport to our hotel or a more personal choice like Uber. While they are both transportation options for getting you to your hotel, anyone who has utilized both options can tell you they are far from the same.

  • Are they both means of transportation? YES
  • Will they both ultimately get you there? YES
  • Will they both get you there in the same time frame? NO
  • Will they both provide the same travel experience? NO

Does the SuperShuttle work for some needs? Absolutely. If you’re looking for a budget-friendly option, don’t mind traveling with strangers and don’t care if it makes 15 additional stops between the airport and your hotel then it’s perfect! Is it the most efficient and comfortable way to travel? No. So you are probably asking – Okay Kristi…what is the point? My point is, most of us would prefer the Uber because it will get us there faster; will be more comfortable, and we will likely have a better experience.  We’ve talked to many appeals and grievances team members who tell us they’re using an appeals and grievances module from a solution that was designed and bought by a completely different department (claims is very common!). Similar to the example above, they may seem similar but if you’ve utilized both options then you know they are far from the same. If your appeals and grievance department is using something other than a solution that’s designed to get you through the process faster, more comfortably and result in a positive user experience then it’s time refer back to my earlier questions…

  • Are they both software solutions? YES
  • Will they both ultimately get you there? YES (hopefully)
  • Will they both get you there in the same time frame? NO
  • Will they both provide the same user experience? NO

There are a variety of tools available for processing appeals and grievances. Some of them can work to get you through the process, but what you should be asking yourself is are they the best solution for accomplishing your end goals and staying compliant. Here are three key reasons you should be utilizing a tool that is designed specifically for your departments’ needs:

  1. Compliance. Are your compliance requirements the same as the claims department? If not, then the solution you are using more than likely is not designed with your compliance needs built in. The cost of non-compliance can be astronomical, and the work involved in fixing errors can increase already high labor costs and consume resources. You need a solution that is designed to help you navigate the ever-changing compliance regulations and automate wherever possible to reduce errors and minimize work. Today’s appeals and grievances software solutions should be flexible enough to change quickly and with limited effort when CMS and other regulatory bodies make changes to the guidelines.
  1. Reporting. A significant part of staying compliant is your ability to see and report on your departments’ activity. Your application should show real-time business insights about your appeals and grievances inventory and operations including workloads, time to process, case status and case compliance. In addition, the solution should provide visual alerts for any case that is nearing it’s compliance deadline or has exceptions. Visibility and alerts enable you to address each situation long before they become major issues. Lastly, the ability to see, filter, splice and neatly report on all the data is imperative. A tool requiring you to spend hours manipulating data not only eats up valuable time and resources but likely will not contain the data in an easy-to-read and digest format. Automated generation of Universe reports and other industry reporting needs can cut hours off process time.
  1. Flexibility. From intake to case resolution an appeals and grievance solution should allow you to dictate what your process needs and when. The steps involved in your departments process are unique to your department and should be handled as such. The ability to make changes when necessary through any step of the process expedites resolution while improving member satisfaction. When evaluating solutions, they should have these basic functionalities and the vendor should be able to easily demonstrate them:
  • Case creation & classification
  • Work-load allocation & balancing
  • Appropriately timed automated correspondence generation
  • Process visibility & automated alerts
  • Efficient case resolution
  • One click report generation
  • Complete audit trail & visibility

A well-designed Appeals & Grievances solution improves compliance, increases productivity, improves quality scores, and boosts member and provider satisfaction. If your team is circumventing, working around or patching your existing dysfunctional solution because it was designed for something other than appeals and grievances, it is time to start building a case for a true Appeals & Grievance solution.