healthcare payer

5…4…3… 2…1 🚀, it’s time to move forward and discover the power of you! This is the message behind the 5 Second Rule by Mel Robbins. It’s a cool, powerful self-help concept I was introduced to while listening to Mel speak recently at Hyland Software’s CommunityLive event in Nashville, TN.

Embracing that concept I say 5…4…3… 2…1 it’s time to take control of your Appeals & Grievances. Standardizing your A&G software applications for all lines of business and improving your process visibility is the key to controlling your cost, maximizing efficiency and improving reporting.  I may have talked to a few professionals in this space over the years so bear with me as I share the common story and/or trend that our A&G team hears on a regular basis.

Once upon a time…

Healthcare Payers of all sizes decided it was best to have a member(s) of their IT/IS staff build an internal custom database to manage their Medicare, Medicaid, and Commercial Appeals. At first it was great! A custom database worked much better than managing cases on paper and excel spreadsheets. It was the path of least resistance and solved the most dire challenge at that moment. But, as time went on the only thing that was constant was change…

Every day the amount of work continues to increase. Membership & enrollment grows and new internal and CMS reporting requirements are required. The custom A&G database that worked so well before is now unreliable and unstable. Sound familiar? The reality is system requirements are continuously evolving and the demands that may be considered at the time of initial planning and development can quickly becomes obsolete. Week after week users submit IT work tickets requesting system enhancements, changes to letter templates and requests to eliminate the manual data entry of numerous data fields that already exists in other core systems like Trizetto. But that custom system wasn’t designed with a forward-thinking element enabling it grow, evolve and change at the rate you need it to.

Then, the dreaded day arrives. Yes, you guessed it – that creator and heroic subject matter expert who built the custom database leaves the organization. System enhancements and fixes now take forever and are more like band-aids then real improvements.  A&G staff members are forced to do their best to complete the work on time and eventually just create their own manual workarounds to track deadlines and status – essentially working around the tool that was developed to improve their efficiency! Increasing workloads and reduced efficiency then results in the Director of the A&G department having to hire additional staff to keep up with the work load, distracting them from focusing on more higher value projects like root cause analysis, data analytics and robotic process automation. This vicious cycle continues until finally someone stands up and says what everyone else is thinking, but too afraid to say: This is crazy…there must be a better way! We need to change what we are doing and build a business case for a solution that helps us work smarter, faster & more accurately. A solution that is dynamic and can change when our needs change. A solution that is built on a single platform, easing integration and maintenance costs. A solution that will evolve – helping us today…and continue helping us into the future. 5…4…3…2…1… 🚀 The Kiriworks A&G solution, powered by OnBase.

5…4…3… 2…1 🚀 What are you waiting for? Listen to Mel and pursue what is meaningful not what is expedient. We are here, how can we help?

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New CMS Guidance

  As part of an initiative to streamline the Medicare Advantage and Prescription Drug appeals and grievance processes, CMS has consolidated Chapter 13 of the Medicare Managed Care Manual and Chapter 18 of the Prescription Drug Benefit Manual into one comprehensive guidance document. They are doing this to better align and provider a more defined, straightforward and non-repetitive understanding of […]

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Your Best Teacher Is Your Last Mistake

5…4…3… 2…1 🚀, it’s time to move forward and discover the power of you! This is the message behind the 5 Second Rule by Mel Robbins. It’s a cool, powerful self-help concept I was introduced to while listening to Mel speak recently at Hyland Software’s CommunityLive event in Nashville, TN. Embracing that concept I say 5…4…3… 2…1 it’s time to […]

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How Painful is Your Contracting Process?

Does your contracting process take forever? Can it take weeks, even months to bring a contract from creation, through negotiation and finally to execution? What causes the bottlenecks and how can they be fixed? First, let’s identify some common hurdles within the contracting process. Once identified, we can implement a contracting management solution to address those issues and reduce contracting […]

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Why CommunityLIVE 2018? So Much More Than Just A Conference…

It was over ten years ago when Hyland took over Nashville and I last took the general session stage at CommunityLIVE (at that time called the OnBase Training & Technology Conference). For those that don’t know my background, I started my career in Content Services at Hyland as a Product Evangelist. This year will be my 12th CommunityLIVE. Now, I […]

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September 26, 2018

Your Best Teacher Is Your Last Mistake

5…4…3… 2…1 🚀, it’s time to move forward and discover the power of you! This is the message behind the 5 Second Rule by Mel Robbins. It’s a cool, powerful self-help concept I was introduced to while listening to Mel speak recently at Hyland Software’s CommunityLive event in Nashville, TN. Embracing that concept I say 5…4…3… 2…1 it’s time to […]
September 19, 2018

How Painful is Your Contracting Process?

Does your contracting process take forever? Can it take weeks, even months to bring a contract from creation, through negotiation and finally to execution? What causes the bottlenecks and how can they be fixed? First, let’s identify some common hurdles within the contracting process. Once identified, we can implement a contracting management solution to address those issues and reduce contracting […]
August 6, 2018

Member Communication: Less Is Not More.

There is no way to sugar coat it – Medicare Advantage plans are not meeting their customer satisfaction goals. Surveys prove it, with satisfaction having dropped from 2017 to 2018. One of the main drivers for the discouraging results is a lack of communication. Health plans are not leveraging communication strategies to engage members even though it’s the most effective […]
June 28, 2018

You Can’t Manage What You Can’t See – Thoughts from the Optimizing Appeals & Grievances Conference

Much of the discussion last week at the Optimizing Appeals & Grievances and Improving ODAG & CDAG Outcomes Conference centered around accountability and company culture.  There was also a great deal of attention given towards the ability to pull Universes on demand.  These topics along with better ways to manage your day to day workloads are common challenges we hear from […]