My complaints about healthcare appeals and grievances: Part 1

insurance-tower-of-babel

I have a complaint.

Actually, it’s more than one complaint. So this is part 1 of a series of grievances about the way medical claims adjusters resolve problems (appeals).

Last I checked, it’s 2015. So why are we still managing issues the same way we did in 1985?

It’s crazy. I could go on and on, but here are my first three complaints about how health plans manage appeals and grievances. Don’t worry, there are more.

1. Our “column and row” addiction
Back in 1985, I was starting my career as an accountant, filling out 11 x 17-inch paper journals by hand to keep track of debits and credits. Zoom ahead 30 years and… you find pretty much the same model to manage grievances and appeals.

What happened? Better yet, what didn’t happen? In a word, technology. But we’ll get to that later.

I’ve interviewed dozens of health plans over the last year to see how they are processing grievances and appeals. All but a few are still using Microsoft Excel® as the “system” to manage them. As a consumer who can use my cell phone to do my banking, my expectations are higher.

Much higher.

2. The Insurance Tower of Babel
Our healthcare system has created a technical Tower of Babel between doctors and hospitals (providers) and health plans (payers). They speak different languages and can’t communicate with each other.

Providers appeal claims by using faxes, emails, portals, phone calls and – of course – snail mail. To accept these appeals, payers create complex technologies using IVR, document scanning, enterprise content management (ECM), workflow, fax routing and ultra-complicated systems integrations. Then they track the appeals in Excel, communicating via paper and phone.

Meanwhile, providers track these appeals in spreadsheets and wait for snail mail to see if/when the payers resolve these claims.

3. Members in the dark
This leaves members in pitch darkness. They listen to the babel coming from the tower and try to figure out how much their visits and procedures are going to cost.

What could make customers, members and consumers feel more powerless than having no idea what’s going on, how much things will cost or when issues will be resolved?

The answer is: Nothing.

I have more complaints. Therefore, in part 2 next week, I will once again appeal for common sense to rule the day. And a dash of technology.

Because I think there are a few of you out there with the same complaints. And it’s time to fix them.

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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