Given unpredictable volume, changing CMS regulations and varying service agreements, managing health insurance appeals and grievances (A&G) is a time-consuming and complex process, especially when done manually.
During a featured session at Becker's Payer Issues Virtual Summit, Tanya McCray, vice president of grievances and appeals for VNSNY CHOICE Health Plans, a part of the Visiting Nurses Services of New York, and Frank Romano, assistant vice president for enterprise architecture at Healthfirst, discussed how their organizations were able to improve A&G processes through automation and implementation of case management tools.
Mike Bernard, sales manager with Hyland Healthcare, the sponsor of the event, moderated the Jan. 26 session.
A&G process challenges, roadblocks
Before updating its processes, VNSNY CHOICE, was using an access database, which is extremely manual and paper-based, Ms. McCray said.
"There was no way to really track or run reports that were actually accurate, keep track of our volume or ... what we had to work on," Ms. McCray said.
Health insurer Healthfirst, while not in an access database, used a system not typically used for A&G that had no embedded workflow or embedded reporting, which resulted in a lot of manual labor, Mr. Romano said. Additionally, the system was approaching its end of life, so Healthfirst needed to find a solution on a more rapid timeframe, Mr. Romano added.
With the various challenges, both organizations saw a huge opportunity to improve their A&G processes with a more comprehensive and automatic solution.
The strategy for improved A&G processes
Both Healthfirst and VNSNY CHOICE began journeys to improve their A&G processes by evaluating several technologies and solutions and establishing must-have criteria.
Healthfirst had several must-haves for the solution, including that it could process both Medicare and commercial cases, reduce the dependency on IT for reports and have embedded workflow capabilities. It also needed to be a cloud-based solution that could be implemented in 18 months or less.
At VNSNY CHOICE, the organization wanted a more comprehensive solution that could automate its notices and letters, run universes in the event of an audit and improve integration capabilities. After evaluating the solutions in the market, both organizations selected Hyland Healthcare's OnBase enterprise information management platform.
"One thing that really made Hyland one of our top vendors to look at was the ability to run universes for CMS auditing, run daily dashboards and be able to just access that system and see everything from soup to nuts for that particular member case," Ms. McCray said.
Measuring ROI and the solution's success
VNSNY CHOICE saw several key improvements after implementing OnBase, Ms. McCray said.
In three years, VNSNY CHOICE saw a 95 percent improvement overall for its A&G processes. It is now able to complete universes at a moment's notice in the event of an audit and monitor its team's dashboards to know if they are responding in a timely fashion. Additionally, the organization saw its accuracy in timeliness for the work processed in OnBase hit 98 percent, Ms. McCray said.
The organization has also been able to improve efficiency to reduce the hours that the team spends on A&G, Ms. McCray said.
"Anyone who's worked in A&G knows that the clock does not stop until the work is completed. We've been able to cut off a lot of the hours that the team is putting in to get work done because it is a more automated system," Ms. McCray said.
For Healthfirst, the primary return on investment was the ability to get off its legacy system in its set 18-month timeframe, Mr. Romano said.
In addition to some of the successes outlined by Ms. McCray, other key successes for Healthfirst included its ability to reduce its dependence on the IT department and realize efficiencies in its reporting, Mr. Romano said.
"Now that we have all of our lines of businesses on the solution, it's really been a saving grace, and I'll just tell you the amount of time that we've spent doing our quarterly reporting for the fourth quarter compared to other quarters has been reduced by more than 50 percent," Mr. Romano said.
Conclusion
Overall, managing insurance appeals and grievances is a time-consuming and complex process. However, by implementing automation and case management tools, payers can improve process visibility, work through higher volumes at a quicker rate and see greater accuracy.
To learn more about how Hyland Healthcare helped the two organizations improve their processes and hear lessons learned during the implementation process, listen to the full session here.