Authored by: Jon Swisher
Appeals and grievances departments work diligently to maintain compliance, keep up with regulations and serve members. However, with large caseloads and many moving parts, manual processes often open up potential risks. As a result, many are turning to data-driven compliance and process automation to mitigate that risk.
“Whenever we discuss process automation, often clients want to do it but aren’t sure where to start,” says Jon Swisher, Director of Sales Engineering, Healthcare at i3 Verticals. “I always say that whenever you’re trying to solve a problem, a good starting point is to begin with the end in mind and decide on what your future milestones will be within the process.”
The path to reimaging processes starts with getting clear about where you are today so you can decide the next best step.
Healthcare payer solutions: The five stages of process automation
Process automation helps reduce compliance risk by creating predefined paths that leverage automation. These predefined paths help mitigate errors and create a safety net for meeting compliance deadlines. When getting started, ask: Where am I today, and where are my competitors? Here’s a quick breakdown of the five stages as you walk through that process.
Stage #1: Initial
In the initial stage, you’re using paper-intensive processes and workarounds that aren’t well defined. Much of data entry is manual, which means you’re inadvertently increasing the risk of errors. Another sure sign you’re in stage one: Your team feels like they’re just “surviving” to get the work done and meet deadlines.
Stage #2: Repeatable
Stage two is far less dire than stage one. You’re getting more organized, but the biggest issue is that you’re still spending too much time tracking documents because of your paper-based processes. Documents fall through the cracks occasionally because so much is happening manually.
Stage #3: Defined
Processes are more defined in stage three. Electronic documents replace paper documents, which is a huge milestone. The risk of documents falling through the cracks is significantly reduced by this change alone. Additionally, multiple process paths in the workflow happen simultaneously through network shares, speeding up productivity.
Stage #4: Managed
Processes have gotten even more streamlined, but the problem is that since you’ve made such significant advancement, complacency kicks in. Workflows and some data entry are automated. You’ve also adopted enhancements supporting compliance, such as historical and business needs reporting. But still, further improvements are possible.
Stage #5: Optimized
Once optimized, you have “straight through” processes in place. In other words, processes happen without your team pushing them along. You also have the flexibility to address exceptions as they come up. In addition to historical reporting, you have real-time reporting.
“Many appeals and grievances teams struggle to get an accurate depiction of their current A&G inventories,” says Swisher. “Having this data is huge for understanding potential liability. For example, if you could total the amount of every claim in your system that could potentially be overturned, that’s important data. But many don’t have access to those insights.”
Healthcare payer solutions and achieving data-driven compliance
Optimization gives you visibility into that information and automatically generates correspondence based on the predefined paths, helping to reduce human errors. Additionally, real-time historical reporting provides complete accounting, tracking every action that occurs in a case. Who viewed the document? Who changed it? Answers to these questions, and many others, are apparent with full recording that can’t be turned off. And it’s these capabilities that provide greater accountability for future appeals and grievances audits.
“We talk to many healthcare payers that are spread out across all five stages,” says Swisher. “Some are at that initial stage, others a little further along, but very few are fully optimized. And it’s our goal to help them get to that ‘fully optimized’ level to improve their productivity and compliance.”