Complaints, appeals and grievances operations are one of the most complex and audited functions of a health plan. Proper management is critical. Leverage ATTAC’s experience and expertise in Medicare, Medicaid, exchange, and commercial lines of business.
Plans face many challenges to properly managing complaint, grievance and appeal operations, including:
- Identifying and interpreting complex federal and state requirements
- Assessing and implementing requirements between federal and state requirements, or for multiple states at a time
- Streamlining processes to meet federal, state and accreditation (NCQA, URAC) requirements simultaneously
- Ensuring systems and processes can execute complex workflows including capture of all data necessary for reporting and auditing
- Implementing effective training across operations to ensure complaints, grievances and appeals are properly handled
Successful management of complaints, grievances and appeals requires:
- Proper identification and interpretation of requirements for classifying all types of complaints, grievances and appeals
- Targeted staff training for detection, routing and resolution of complaints, grievances and appeals
- Structured process workflows for timely and compliant processing
- Standards for data capture and case documentation to support regulatory reporting and audit fulfillment
- Robust monitoring and quality review programs to monitor trends and remediate risk throughout the organization
Leverage ATTAC’s experience and expertise in Medicare, Medicaid, exchange and commercial plans in the following areas:
- Development of documentation standards and training
- Operational and systems workflow design
- Procedure assessment, development and enhancement
- Technology/systems evaluation and implementation support
- Internal and external reporting
- Regulatory monitoring and advisement
- Compliance evaluation
- Data validation and compliance testing
