Appeals & grievances: 3 tips for the daily triathlon

Hurley Chicago Tri Photo 1

A few weeks ago, I completed my first triathlon. Reflecting on the event, I realized that Appeals & Grievances (A&G) managers run a triathlon every day.

Triathlons include three events in succession and it’s all about the clock. In an Olympic Triathlon – like I participated in – you start with a one-mile swim, transition to a 25-mile bike ride and finish with a six-mile run.

Swimming against the flow of appeals

With A&G, plans must swim against the strong flow of appeals coming in from every direction. And those appeals can arrive via paper, fax, email, phone, portal or any other method doctors and members can conceive.

In this first event of the daily A&G triathlon, managers must not only catch every appeal in every format, but must also quickly triage them, determining which will require special attention – all while swimming and watching the clock, of course. For me, the swim was the toughest event, because the waves were coming from all directions, everyone is fighting for position and it’s just the beginning of a long, tough day.

I think that this holds true for A&G Managers as well. Stroke after stroke, these managers wonder if an appeal has slipped past like so many tiny fish in the current.

Biking the hills

As our managers transition to the second event of the day, they barely have time to break for a cup of coffee. Now it’s all about focus and measurement. Well into the race, they must focus to make sure every appeal is carefully researched and documented according to the Centers for Medicare & Medicaid Services (CMS) requirements. It’s all about adjusting to the speed attained flying down the hills and the slowness of slogging back up them.

During my race, I periodically glanced down at my Garmin to see my time, heart rate and distance – those all-important vital stats that tell me how I’m performing. Unfortunately, A&G Managers rarely have such timely or precise information. There’s no time to rest, because as soon as they finish the bike, they need to transition to the run.

All while the clock is ticking!

Running to the finish line

In the third and final event, managers must dig deep to find the energy to create and review reports for their teams, executives and agencies like the Department of Insurance and CMS. This event is complicated as they juggle deadlines, disconnected systems and a version of MS Excel that hasn’t been upgraded since the 2000 Sydney Olympics.

During my triathlon, the temperature was more than 80 degrees Fahrenheit and there was full sun when we started. It was hot! Unfortunately, managers must deal with another type of heat in their run – the pressure of annual audits.

As I crossed the finish line of my triathlon, I was filled with pride and relief that I had made it. I was done. I could go enjoy my banana and bagel – and then go take a nap. Our managers aren’t so lucky. As they leave for the night, they know tomorrow’s triathlon starts at 8:30 a.m.

Preparing for the race

I placed this section last because as an A&G manager, you either just finished a triathlon, did one yesterday or you’re in the middle of one right now. The point is: You don’t really have time to prepare because you’re already racing.

While I strongly believe that enterprise content management (ECM) can help you continually set new personal records (PRs), these training tips will help you along during your own daily triathlon:

  1. Start with the end in mind. My goal was to finish my first triathlon. Your goal for appeals needs to focus on improving key metrics. Perhaps your key metric is “cost per appeal” or “average time to close an appeal.” Whatever the metric you want to improve, that needs to be where you start your training.
  2. Face the cruel facts. I started my training with an assessment of my current physical condition. There was no sugarcoating the fact that I needed to work on some key deficiencies in my fitness. So you must face the reality of your current department, resources and processes. Honestly understanding where you are allows you to focus on the aspects of your daily triathlon that you need to improve.
  3. Set some short-term goals that you can focus on. It was hard for me to think about completing an entire triathlon, but when I focused on setting a goal to get in the pool four times a week, swimming became easier and the tri did not seem so daunting. Set some measurable, reasonable, short-term goals that you can achieve and that get you closer to success in your appeals process.

To successfully reach the finish line, again and again, the key is setting a pace that you and your team can handle. By treating you’re A&G tasks like a triathlon, you can figure out which events present the most challenges and then focus your training on those.

For me, it’s still the swim. What is it for your team?

Mike Hurley

Mike Hurley is the industry manager for Health Insurance at Hyland, helping health insurance organizations transform business processes that drive value for members, providers and employees. Mike works with current and prospective customers to use our award-winning product, OnBase, to drive business transformation. He is also responsible for our high-value, high-impact health insurance solutions, the like Mobile Medicare Enrollment Solution for OnBase. Prior to joining Hyland, he was the founder and president of Swim Lane Software, LLC. Hurley founded Swim Lane in 2007 to create a solution that leveraged Software as a Service (SaaS) technology to automate the processing and adjudication of Medicare Claims through unique use Business Process Management (BPM) and Business Rules Management Systems (BRMS) technologies. Preceding Swim Lane, he founded Green Square in 1997 as a national consulting practice that connected technology with business strategy. As a boutique services firm, Green Square was aimed at driving stakeholder value at over 25 BlueCross BlueShield plans in the U.S. Prior to Green Square, Hurley founded Avalon Technologies, Inc., an award-winning systems integrator focused on Enterprise Content Management (ECM), workflow and Optical Character Recognition (OCR) technologies.

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