My complaints about healthcare appeals and grievances, part 2: Is reportlessness a word?


In my previous post, I promised more complaints about how healthcare plans manage appeals and grievances. These opinions originate from spending the last several months surveying healthcare plans and talking to them about how they handle these services.

Be prepared, by part 3 of this series, we’re going to move past the fun part of identifying issues and start solving them. But until then, here are three more issues with healthcare appeals.

Do any of them sound familiar?

1. Reportlessness
Ok, reportlessness may not really be a word, but it pretty accurately describes the miserable time most healthcare plans have reporting on complaints. As I described in my previous post, 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.

Not, analysis just compilation.

2. 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 and 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.

3. UnBeancountable
The last of my metaphors is a bit personal. I am a recovering accountant. I still look back at my junior accountant days using VisiCalc to slay financial dragons with a bit of longing nostalgia. So it is a bit painful for me to report that for all but a very few appeals processes that I have 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 am sorry to say that in spite of MS 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 each an appeal costs, can’t measure it as a key metric, and haven’t a clue whether it is going up, down or sideways.

I really do have a bunch more complaints, but I think you get the idea. Because as I said, in part 3, we’re going to move past the phase of shouting at the desert.

We’re going to talk about some things we have learned about how complaints are a golden opportunity to show members and providers how much healthcare plans love them.

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