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Writer's pictureAlexander Earlywine

Appeal & Grievance Platforms

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:

  1. Utilization Management

  2. Care Management

  3. Pharmacy

  4. Legal

  5. Claims

  6. Finance

  7. and more...


Grievances:

  1. Contact Center

  2. Enrollment

  3. Billing

  4. Sales & Retention

  5. Plan Design & Benefits

  6. Quality of Care

  7. Quality of Service

  8. Access to Care

  9. Privacy Concerns

  10. Pharmacy & Formulary

  11. Marketing

  12. Claims & Disputes

  13. Appeals

  14. Clinical Staff

  15. 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.


Newgen's CAG Solution Product Pack consists of 6 Modules, available independently or as a package

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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