My complaints about healthcare appeals and grievances, Part 3 – 4 steps to optimize your solution


In my previous posts, I lamented the myriad challenges payers face with healthcare appeals and grievances. It is now time to stop complaining and offer some solutions.

Here are my long-promised 4 steps to optimize your appeals and grievances process:

1. Make complaining easy (and listen)
Why make it easy? Complaints are data about what you could do better. They are an early warning detection system that directly affects member and provider satisfaction. So making it ridiculously simple to file an appeal or grievance (complaint) is definitely in your best interest.

But don’t forget to make it inexpensive!

Reduce your cost-per-complaint by automating every possible step in the process, whether complaints come from paper, fax, email, voicemail, CSR call, walk-in or Tweet.

Then, after you make it easy to complain, make sure you listen. That completes the cycle and brings it all back to the ultimate goal: Affordable health care.

2. Reward frequent complainers
Yes, I really do mean it. Frequent complainers are your best critics. And they are immensely valuable. Reward them with Starbucks or Amazon cards. And letters signed by your CEO thanking them for taking the time to point out something you could do better.

If not the CEO, how about you? Again, the key here is to find a solution that compiles this kind of data and makes it easy to find frequent complainers. So you can fix those issues.

Then, you can give those “complainers” hugs for helping you get better at what you do. Or gift cards, if they’re not into the whole hugging thing.

3. Encourage good complaining etiquette
Design a transparent, automated solution that rewards e-complaints over paper or fax. If you must use paper or fax, make forms easy to read (via OCR and bar coding) on your end and offer speedier processing times for those complaints that come in via preferred methods.

How about something like, “We process e-form requests in 24 hours. We process mailed requests 24 to 48 hours after arrival.”

A robust enterprise content management (ECM) solution will provide portal access or OCR for paper, fax and emailed complaints. After your initial investment, you immediately begin decreasing costs and processing times, giving you the ability to provide superior service.

4. Squeeze every nickel
Buy your accountant lunch. Then ask her to help you establish a cost-per-complaint. Once you have that – and after you take a few antacids – look for a solution that tracks every single touch of a healthcare appeal or grievance and then provides tools for trending and analytics based on cost-per-appeal/grievance.

My mission is to empower healthcare plans to turn every single complaint into an opportunity for a hug. Managing appeals and grievances with MS Excel and Outlook is outrageously expensive, fraught with quality challenges and makes it difficult to deal with CMS compliance mandates. It’s not the way to go, especially during the Digital Age.

So, are you ready to hug your appeals and grievances?

If not, check out part 1 and part 2 of the series.

Mike Hurley is the industry manager for Health Insurance at Hyland, helping health insurance organizations transform business processes that drive value for members, providers and employees. Mike works with current and prospective customers to use our award-winning product, OnBase, to drive business transformation. He is also responsible for our high-value, high-impact health insurance solutions, the like Mobile Medicare Enrollment Solution for OnBase. Prior to joining Hyland, he was the founder and president of Swim Lane Software, LLC. Hurley founded Swim Lane in 2007 to create a solution that leveraged Software as a Service (SaaS) technology to automate the processing and adjudication of Medicare Claims through unique use Business Process Management (BPM) and Business Rules Management Systems (BRMS) technologies. Preceding Swim Lane, he founded Green Square in 1997 as a national consulting practice that connected technology with business strategy. As a boutique services firm, Green Square was aimed at driving stakeholder value at over 25 BlueCross BlueShield plans in the U.S. Prior to Green Square, Hurley founded Avalon Technologies, Inc., an award-winning systems integrator focused on Enterprise Content Management (ECM), workflow and Optical Character Recognition (OCR) technologies.
Mike Hurley

Mike Hurley

Mike Hurley is the industry manager for Health Insurance at Hyland, helping health insurance organizations transform business processes that drive value for members, providers and employees. Mike works with current... read more about: Mike Hurley