appeals and grievances

What is pain? Pain is physical suffering or discomfort caused by illness or injury. Pain motivates you to withdraw from damaging situations, to protect your body and to avoid similar experiences in the future. How many times do we have pain but ignore it? I know I have. I was running a 5K and BAM about half way through I had a shooting pain coming from the bottom of my foot.

I was new to running and thought, “Maybe I just stepped on something and the pain will go away” So, I continued to run and the pain continued. I crossed the finish line and convinced myself I was fine and it would go away on its own. Off to my touch football league I went, where I continued to hammer down on my foot. We won the game, but I was in much more pain than when I started and the pain wasn’t going away. I went to get an x-ray and found out…I fractured my foot! Pain diagnosed and treatment plan in place that left me in an air cast for the whole summer. No more running for me.

What’s the point of sharing this story with you? Pain is usually the first sign that something is wrong and when you ignore it – it makes things worse. It’s time to listen to your pain and make changes to treat it. This applies to your work pain as well as physical pain. Think about your work tasks and what pains you experience on a day to day basis. Chances are you can rattle off a few issues you run into each and every day that you absolutely dread and think to yourself…there has to be a better way. Process bottlenecks, oversights, manual mistakes, missed communications, the list can go on and on. We feel the pain but one of the hardest parts can be diagnosing the exact pain point and building an effective strategy to treat it.

When CMS published the latest STAR ratings for health plans, how did your plan fare? The average STAR rating was a 3.7 so it’s clear that timeliness of appeals is a major pain for some health plans. Health plans are not responding in a timely manner to plan members when they make an appeal request and it is impacting their ratings, member satisfaction and ultimately their profits. How can you ensure timely responses and reduce this pain? Start by building a treatment plan that leverages technology and software solutions designed to automate your business process. These solutions not only reduce the manual steps within your process, but utilize timers and notifications to ensure timeliness. As soon as an appeal is submitted, the clock starts. The solution will notify all parties that need to be involved in the decision and kickoff the communication process. As the clock continues to run, delay notifications and status updates will engage additional staff if necessary and keep the process moving. Daily reports provide management with status updates and insight into the process so necessary adjustments can be made to meet required timeframes and improve service.

We can become so used to doing things a certain way that we don’t even consider that there could be an easier way. Pay attention to the pain you’re feeling and use it to your advantage to improve your life, both at home and at the office. It will guide you down a path of increased productivity and efficiency.

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Building a Strong Network: It Takes an Empowered Team

Life is full of different experiences. Take a moment to think about the last really good experience you had. What was it about the experience that made it so positive? Now think about the last horrible experience you had. What was it that made the experience so poor? I’m betting that the factors behind why your experience was positive or […]

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The Secret to Improving Member Experience? Hint: It’s Probably Not What You Think.

Life is full of different experiences. Take a moment to think about the last really good experience you had. What was it about the experience that made it so positive? Now think about the last horrible experience you had. What was it that made the experience so poor? I’m betting the factors behind why the experience was positive or negative […]

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Digital Transformation in Manufacturing: Getting You Ready For Race Day

A couple years ago when I started thinking about running my first half marathon I knew it was going to be a real project and a real commitment. See, running doesn’t come easily or naturally to me and I don’t hesitate to say I’m usually bringing up the rear in most of my races. Although I’ve been an athlete my […]

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Bad Data Is No Different Than No Data.

Imagine if each time you entered an address into your GPS you only had a 50% shot that you would arrive at your correct location. You would be pretty upset if you weren’t in the 50% that made it to their destination. That is precisely what CMS has uncovered during round two of the online provider directory review. The average […]

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December 11, 2017

PAIN…a sign that change is near.

What is pain? Pain is physical suffering or discomfort caused by illness or injury. Pain motivates you to withdraw from damaging situations, to protect your body and to avoid similar experiences in the future. How many times do we have pain but ignore it? I know I have. I was running a 5K and BAM about half way through I […]
August 31, 2017

Things That Are Better Together

There are many things in this world that make us happy and bring us joy. Sometimes when those great things are combined with other wonderfully, great things they become AMAZING! Simply put…they are Better Together. Here are a few of those amazing things: Peanut butter and jelly Milk and cookies – especially chocolate chip! Netflix and your couch Danny and […]
July 12, 2017

Uncertainty…How are you handling it?

Studies have shown that most people would rather be unhappy than uncertain. But when you are unhappy, you are less motivated, more stressed and may just feel lost. Why would you want to feel that way? And doesn’t that seem worse than being uncertain? Plus, how you deal with uncertainty can define your path towards happiness and overall success! So […]
March 16, 2016

Gateway Health(SM) Selects Kiriworks Appeals & Grievances Solution

Appeals & Grievances solution supports Gateways belief in “A Better Way” Milwaukee, WI, March 15, 2016 – Gateway Health, a top ranked Medicaid and Medicare managed care organization has been delivering quality and affordable healthcare to its members for over 20 years. In concert with Gateway’s strong commitment to doing things “A better way” the selection of Kiriworks as their […]