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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 health plans all the time. How do we better manage the process, report on it and hold our team accountable – while creating a culture where employees thrive and member service is the highest priority? It’s easier said than done but it starts with a very simple focus – “you can’t manage what you can’t see.

  • In our experience most plans are manually generating reports in a batch process.  Because it’s a time-consuming, manual process that usually requires the involvement of your IT team, by the time you receive the report the data is obsolete and useless. Your A&G solution needs to have the ability to deliver real time reports providing you with the data you need – RIGHT NOW. For example: how much more efficient could you be if your personal dashboard could immediately let you know how many active cases you currently had, which cases are due today or in the next 72 hours? The data image below provides that…and more.

  • If you asked one of your A&G professional to describe in one word the department culture, what adjective do you think they’d use? It’s unfortunate and unnecessary that so many A&G departments are surviving and not thriving.   What I mean by that is often times the A&G department is so busy and has so many cases that teams process incoming cases almost like the checking of tasks: a case comes in, a case is added to a workload, a case gets processed and then rinse and repeat for every incoming case.  This is okay and a portion of the time you and your team may be able to complete the necessary work within the required deadlines. What happens when that isn’t enough, when the workload exceeds the bandwidth or when your employees start burning out? Forward-thinking managers are developing strategies NOW for future improvement and focusing on ways to speed up processing times, avoid bottlenecks and crafting innovative and creative ways to empower employees to improve customer service. Health plans with a focus on employee and member satisfaction are not just sitting back content with accomplishing the status quo, instead they are utilizing the tools and technology that will put them ahead.  Your real time reports should be delivering you the data analytics to make changes that can improve the service you are providing your members and avoid employee burnout.

  • Once you have the tools to see into your process and start identifying improvement opportunities, you are now armed to to tackle any audit or Universe generation – ON DEMAND. Innovative A&G solutions have built-in CMS data to automate report generation with the click of mouse. It is no longer necessary to involve IT or wait on others to access the information you need whenever you need it. Personalized dashboards enable you to customize your views with the info, reports and activity you use/need most.

 

We know it doesn’t just stop there. In the world of Healthcare Payers and Appeals & Grievances, reporting demands change and evolve all the time. We’ve already started on the 2019 Universe table changes and as your partner we are committed to keeping you one step ahead. Your success is our focus. I’d like to close up my thoughts by thanking Tim and Audrey of RISE, all of the presenters, and the conference sponsors. We were honored to be a part of the event and to continue offering you dialogue, ideas and solutions to your biggest process challenges. On behalf Jon and Matt, we had a wonderful time and look forward to seeing everyone next year.

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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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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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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 […]
May 22, 2018

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 […]
May 22, 2018

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 […]
March 27, 2018

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 […]