By law, members of health insurance providers have the right to appeal any decision made by the provider. Members may also submit grievances expressing dissatisfaction with any aspect of the operations, activities or behavior of a Medicare health plan, or its providers, regardless of whether remedial action is requested. Providers who do not strictly follow the laws involving Appeals and Grievances (A&G’s) are subject to regulatory fines. In 2007, United Healthcare paid $12 million to 36 states for improperly processing A&G’s. In 2009, Arizona regulators fined another health provider, Health Net, $236,500. On average, providers allocate $2.50 per member per month to process A&G’s. Annual costs for a company such as Touchstone can easily reach as much as $600,000.
Touchstone was managing 1,500 A&G cases per month, through a largely manual case management process. The case managers had to gather data from multiple systems and departments, manually reconciling all reporting, and manually generating and tracking the required correspondence and deadlines. Additionally, the case managers often lost visibility and control when assigning cases throughout the organization.
Touchstone’s CIO considered numerous solution providers, but selected BizFlow Plus BPM Suite as it competed very effectively on all major Business Process Management (BPM) criteria, and provided the extra benefit of handling structured and unstructured processes, a crucial element of Touchstone’s A&G processes. BizFlow Corp’s long time expertise in BPM added extra value, and Touchstone was impressed with the team’s responsiveness and speed as a vendor and trusted advisor.
System Consolidation and General Automation – Now, when a call comes in, the A&G case manager opens the one and only system necessary and notes all relevant details of the case. Based on these details, it is automatically determined where to go for the needed data. The automation makes it possible for these assignees, in turn, to sub-delegate the work as needed. In addition, the automation allows the system to generate data exports to a fulfillment house – this allows Touchstone to quickly and easily generate customized member correspondence, helping to strengthen member relationships while reducing operating costs and compliance risks. The automated system dynamically adapts on a case-by-case basis – this provides flexibility, while allowing the case manager to maintain control and visibility.
Case Management – Prior to automation, when a call came in with a complaint or question from a provider or beneficiary, A&G case managers would have to gather data from multiple systems and departments. This made it extremely difficult to keep track of each claim and handle it effectively and efficiently – everything was done manually. Cases are now much more streamlined and easy to handle. The case manager opens the system to input basic information; the system then determines where and who the necessary information should come from, and enables the manager to track where the claim is at any time. The claim can easily be tracked in the system all the way through to completion.
Simplification – The impact to Touchstone has been immense. The automation has significantly simplified the jobs of the A&G case managers. The training method for case managers is more efficient, as case managers now only have to learn one system. Before automation, the case manager would be required to sift and sort through many different systems to try to determine what information was needed to process the claim, and where they had to go to get this information. Now, it is far easier to determine and locate this information, as everything is consolidated into one system. Since only one system is used, delegating work has never been easier. It’s all contained in one spot, allowing anyone to easily track where in the process the claim is, who is in charge of each task, and when the task was assigned to them. In addition, the automation allows the system to generate data exports to a fulfillment house – this allows Touchstone to quickly and easily generate customized member correspondence. This ability to generate correspondence has helped to strengthen member relationships while reducing operating costs and compliance risks.
Overall, case handling has been greatly improved. Case managers now have greater control of the process, while tasking others for input to the case, and improving processing time significantly. The automation also ensures adherence to CMS regulatory requirements. Leveraging BPM and automating this system has reduced the learning curve and skill level needed for processing A&G’s by consolidating all required systems into a single case management tool. The automation has saved eight hours of manual work weekly on reporting reconciliation alone; countless hours have been saved on the generation and tracking of correspondence.