For almost twenty years, I have been responsible for owning or transforming the Appeals & Grievance teams. I've often referred to it as the toughest department to work in within a managed care organization. Why? Because it interacts with every part of the organization. See below for more details.:
Appeals:
Utilization Management
Care Management
Pharmacy
Legal
Claims
Finance
and more...
Grievances:
Contact Center
Enrollment
Billing
Sales & Retention
Plan Design & Benefits
Quality of Care
Quality of Service
Access to Care
Privacy Concerns
Pharmacy & Formulary
Marketing
Claims & Disputes
Appeals
Clinical Staff
and more...
As a business owner and consultant in this field, I've engaged with almost all major platforms, including Pega, Newgen, Salesforce, Hyland, MedHOK (MHK), and custom-built applications. Initially, these platforms primarily aimed at digitization—transitioning from paper to electronic files—and ensuring compliance. Nowadays, customers seek not only compliance but also assistance from robotic process automation (RPA), machine learning (ML), and artificial intelligence (AI). From my experience, A&G in government insurance, particularly Medicaid, places a significant burden on most systems, necessitating a robust low-code structure to accommodate continuous regulatory changes and the wide variety of products.
I've taken a moment to outline 3 solutions I've worked heavily with as a business owner and consultant. The represent 3 different approaches to systematic solutioning:
Newgen: Heavily configured and ready to use, but allows systematic changes and customizations at low cost. Great, overall solution.
MHK: SaaS solution prohibiting most customizations in favor of a standardized and structured compliance approach. Excellent tool from a compliance perspective, but lacking innovative features.
Pega: Start with a very light accelerator and build it yourself approach. Requires heavy internal knowledge or expensive consulting costs to complete design and heavy development costs.
I have designed the grid below, drawing from my own experience as well as that of my team and consulting clients. Yellow signifies that the solution satisfies the fundamental requirements, while green represents the inclusion of the most advanced features available today. Areas marked in red are considered risky, indicating that action or an alternative purchase is necessary to achieve your objectives.
After years of searching for the right platform, I have partnered up with Newgen on their Complaints, Appeals & Grievances product suite infusing what i've learned into their industry leading NewgenONE platform to create the Complaint, Appeal & Grievance (CAG) Product Suite. Its ready for Medicare, Medicaid, ACA/Exchange and Commercial Markets.
Contact Newgen with questions and to request a demonstration
Need help with a Appeal & Grievance, Managed Care, IT or M&A project? Reach out to me with any questions.
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