Managing appeals and grievances is labor intensive and challenging as it involves keeping up with the policies and guidelines regulating the process while providing greater transparency to member and providers on the process. Payers are further paying fines for not handling appeals and grievances timely and accurately.
Our platform allows digital submission of appeals in a guided fashion that notify on chances of appeal overturn or upheld decision during submission, compliance with medical policy and medical necessity and provides insights and transparency to documentation needs, form completion accuracy to reduce time taken to resolve and volume of appeals.
Key Challenges
- Time consuming process
- Fines for not handling appeals and grievances timely and accurately
- Lesser transparency to member and providers on the process
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The Solution
Digitization of appeals and grievance process in a guided fashion to resolve in shorter time span
- Our platform performs an almost no touch intake of appeals across channels – fax, email, portal, call or file based. It uses smart routing techniques with decision recommendations, next best action to resolve appeals.
- Inbuilt AI/ML algorithms in our platform validate medical necessity and provide insights into the medical policies. It helps the executive to resolve the appeal efficiently and the submitter to include accurate information during submission.
- Our platform automates letter authoring and communication with members and providers based on configured communication channel preference
- Our platform has inbuilt AI/ML to predict increase in volumes of appeals and alerts when the current workforce is not enough to keep up with the SLAs so that they can be managed better.
Reduced Time and Volume
- Provide transparency to members and providers to reduce appeals resolution time and volume
Benefits
Digitized appeals intake and resolution
Insight driven advise on appeal compliance with medical policy
Automated communication on appeal resolution
Prediction and management of surge in appeals
