Complaints and solutions for the healthcare appeals and grievances problem

A medical professional works on a computer.

In this piece:

I have a complaint.

Actually, it’s more than one complaint. And they are all about the way medical claims adjusters resolve problems (appeals).

Last I checked, we entered a new century some time back. So why are we still managing issues the same way we did in 1985?

It’s crazy. I could go on and on, but the following are what I see as the biggest issues with how health plans manage appeals and grievances.

Don’t worry, though. I don’t only plan on complaining. After we cover the biggest challenges, we’ll dive into the best ways to optimize your appeals and grievances processes.

6 hurdles to a success appeal and grievances process

1. Our “column and row” addiction

Back in 1985, I was starting my career as an accountant, filling out 11 x 17-inch paper journals by hand to keep track of debits and credits. Zoom ahead nearly 40 years and … you find pretty much the same model to manage grievances and appeals.

What happened? Better yet, what didn’t happen? In a word, technology. But we’ll get to that later.

I interviewed dozens of health plans to see how they are processing grievances and appeals. All but a few are still using Microsoft Excel® as the “system” to manage them. As a consumer who can use my cell phone to do my banking, my expectations are higher.

Much higher.

2. The insurance “Tower of Babel”

Our healthcare system has created a technical Tower of Babel among doctors and hospitals (providers) and health plans (payers). They speak different languages and can’t communicate with each other.

Providers appeal claims by using faxes, emails, portals, phone calls and — of course — snail mail. To accept these appeals, payers create complex technologies using IVR, document scanning, enterprise content management (ECM), workflow, fax routing and ultracomplicated systems integrations. Then they track the appeals in Excel, communicating via paper and phone.

Meanwhile, providers track these appeals in spreadsheets and wait for snail mail to see if or when the payers resolve these claims.

> Read more | Future-proofing the healthcare payer infrastructure

3. Leaving patients in the dark

This leaves patients in pitch-black darkness. They listen to the babel coming from the tower and try to figure out how much their visits and procedures will cost.

What could make customers, members and consumers feel more powerless than having no idea what’s going on, how much things will cost or when issues will be resolved?


4. Reportlessness

OK, “reportlessness” may not be a real word, but it pretty accurately describes the miserable time most healthcare plans have reporting on complaints. As I previously wrote, Microsoft Excel is the tool du jour.

Staff members typically compile reports through sheer brute, manual force. They are therefore difficult, expensive and devoid of useful information. This continues to surprise me as I talk to healthcare plans. At one organization, there were two full-time employees just compiling reports.

No analysis — just compilation.

5. Data desertification

Perhaps I am bending the English language again for this metaphor, but I think you get the point. Most healthcare plans live in a data desert.

As the phrase implies, for most healthcare plans, there is simply not enough good data for analytics, budgeting or trend analysis. Reportlessness, described above, is the natural state if you live in a data desert.

I find it truly ironic that we live in an age where data is literally everywhere our smartphones go, but for most healthcare plans, useful appeals and grievances data slips away, like sand through their fingers.

6. UnBeancountable

The last of my metaphors is a bit personal. I am a recovering accountant. With a bit of longing nostalgia, I still look back at my junior accountant days using VisiCalc to slay financial dragons. So it’s a bit painful for me to report that, for all but a very few appeals processes I’ve seen, the bean counters are locked out.

I have yet to meet with a healthcare plan that can declare their cost per appeal (or grievance). Say it ain’t so, you say?

I’m sorry to report that, in spite of Microsoft Excel being used in many clever ways, I rarely see the accountants at the tables with their cost-per-transaction spreadsheets. The clear implication is that we don’t know how much an appeal costs, can’t measure it as a key metric and haven’t a clue whether it is going up, down or sideways.

4 steps to optimizing appeals and grievances

Now that I have lamented the myriad challenges payers face with healthcare appeals and grievances, it’s now time to stop complaining and offer some solutions.

Here are my four 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. Making it ridiculously simple to file an appeal or grievance (complaint) is definitely in your best interest.

And 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 gift cards or 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. That way, you can fix those issues.

Then, you can give those “complainers” a benefit for helping you get better at what you do.

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 within 24 hours. We process mailed requests 24 to 48 hours after arrival.”

A robust 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. Managing appeals and grievances with Excel and Outlook is outrageously expensive and fraught with quality challenges as well as 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 make your appeals and grievances work for you?

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Mike Hurley is a veteran health insurance expert and contributor to the Hyland Blog.
Mike Hurley

Mike Hurley

Mike Hurley is a veteran health insurance expert and contributor to the Hyland Blog.

... read more about: Mike Hurley