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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New Innovations: Provider Outreach

The software industry today is a diverse and dynamic industry with products readily available to meet just about every business need imaginable.  But what do you do when you need a product that can send thousands of surveys, attestations, or general outreach to your providers?  What options are you using when you need the data to be returned to your […]

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The 10-Year Challenge

The most recent social media trend has been the 10-year challenge, when an individual posts a picture on a social media platform like Facebook, Instagram, Snapchat or Twitter, and compares a picture of themselves from 2009 to 2019. Which typically sparks a conversation between followers and friends of how so much has changed within the 10-year time span.   2009 to today has […]

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Don’t listen to what they say – GO SEE.

Greetings and welcome to 2019!   As you begin planning your new year and accomplishing goals, we wanted to share with you some upcoming healthcare related conferences we will be supporting in February, March and April. First we’re looking forward to getting out of the Cleveland winter and heading to at HIMSS19 in Orlando, Florida.  Seema Verma and Alex Azar will […]

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Submit or Not to Submit? That is the AOR question.

Appointment of Representative, (aka the AOR) always seems to be a topic of conversation in the healthcare payer space. Every show we attend, every customer we talk with and every industry function we attend, there are intense conversations and differing opinions on what is required by CMS. Do you only submit an AOR once? Do you need to submit a […]

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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 […]