Achieving A&G excellence in healthcare

Given the fluctuating volume, constantly changing industry regulations and varying service agreements, managing health insurance appeals and grievances (A&G) is a time-consuming and complex process, especially when done manually. Moreover, this process plays a pivotal role in determining member and provider satisfaction with a payer, a metric of increasing importance in a highly competitive marketplace.

The right technology can be instrumental in enhancing healthcare A&G processes, as illustrated during a featured session at Becker’s Payer Issues Virtual Summit. The session, titled Challenges and Opportunities Within The Appeals and Grievances Process, featured Tanya McCray, vice president of grievances and appeals for VNSNY CHOICE Health Plans, and Frank Romano, vice president for enterprise architecture at Healthfirst.

Both speakers highlighted how the implementation of OnBase, Hyland’s enterprise information platform, helped their organizations digitize and automate key portions of the A&G process while streamlining case management.

Outdated technology creates A&G roadblocks

Both VNSNY CHOICE and Healthfirst were dependent upon older, legacy technology systems for A&G management prior to implementing OnBase.

For VNSNY CHOICE, it was a legacy database. Entering data into this system was a manual and inaccurate process. Furthermore, the system didn’t provide the reporting capabilities for the payer to effectively track even the most basic metrics, such as volume.

Healthfirst’s legacy system was a bit more sophisticated, but it didn’t offer embedded workflow or reporting. Plus, it was approaching its end of life. The health plan needed to replace the system within an 18-month window, otherwise it would be left with a system its vendor would no longer support.

Out-of-the-box universes and IT independence deciding factors in A&G technology

VNSNY CHOICE and Healthfirst had similar criteria for evaluating a new technology system to support A&G management. Medicare was a huge area of growth for both health plans, so the ability to generate CMS audit universes out of the box was a must. Furthermore, the existing systems at VNSNY CHOICE and Healthfirst both required heavy IT support and involvement.

“We were dependent on IT for reporting,” said McCray. “We wanted to reduce that dependency, and we were also looking for a solution that would automate our notices and letters.”

For Healthfirst, a solution they could deploy in the cloud was a key deciding factor as well, because it would align with a broader company goal to become 100 percent cloud-based and would support the rapid deployment necessary to meet the plan’s 18-month implementation window.

A&G automation results in tangible ROI

This evaluation criterion led both plans to select Hyland OnBase as their A&G management platforms. They realized the impact of these decisions quickly after implementation.

“With OnBase, we’ve been able to provide universes on demand and are looking to automate 75 percent of our intake entry by the end of the year,” says Romano. “Furthermore, the time we’ve spent doing quarterly reporting has been reduced by more than 50 percent.”

Similarly, VNSNY CHOICE has seen 95 percent improvement in its A&G processes after the first three years of use. The plan also is achieving 98 percent accuracy and timelines for the work processed in OnBase. All of which has a huge impact on the company’s ultimate goal of member satisfaction.

“Many health plans are focusing on improving member and provider satisfaction,” says McCray. “A&G tells the temperature of your organization. Having a system that can identify who is complaining, what the complaints are about and what the root causes are lets the organization pivot to change certain processes and address failures in A&G process.”

You can view the entire recorded Becker’s Payer Issues Virtual Summit session on demand here. We also invite you to review the A&G capabilities of OnBase here as well as VNSNY CHOICE’s full case study.

Ken Congdon

Ken Congdon

Ken Congdon is the team lead of solution marketing at Hyland. His mission is to develop engaging content that educates healthcare providers and payers about potential solutions to their most... read more about: Ken Congdon

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