Julie Billman

Complaint Management – Identifying the Riptides Drowning Your Health Plan

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Do you know the signs of a riptide? Often the general public isn’t aware of riptides when they go to the beach. The change in the way the water moves and breaks on the shore is something lifeguards keep an eye on to keep swimmers safe.

Health plans need to have the same kind of diligence in reviewing our members’ experiences with our health plans. This ensures members, often at their most vulnerable, are safe and well taken care of. One of the main ways to identify problems within your organization is through identifying, reviewing, tracking, and trending all your grievances and appeals. Regan Pennypacker, Gorman Health Group’s Senior Vice President of Compliance Solutions, states that reported complaints are gifts to the health plan. How true that is! It gives health plans an opportunity to understand what is happening in the real world and how the health plan activity is perceived. More importantly, since the issue was reported, there is an opportunity to fix the issue – not only for that member but for all impacted members

How do we make the most of our reported complaints? Here are four areas each plan should focus on to make the most of the gifts the health plan receives:

Gather Complaints from All Sources – Most complaints come in through Customer Service, but often some of those complaints are not captured. The Centers for Medicare & Medicaid Services (CMS) instituted call logs as part of their program audit protocols because its review often identified member calls that were not recognized as complaints. Additionally, some complaints come in through other sources such as member discussions with case or disease managers, member calls to vendors, or complaints included on other member-submitted correspondence like written on premium invoices returned with payments.

Educating all staff on how to recognize complaints and how to forward them to the correct area is an important first step. Further action can involve reviewing call notes for key words, but remember to include words beyond “angry” or “upset.” Some members are sad, devastated, or crying when they are complaining to the health plan.

Additionally, health plans need to confront the concern that by identifying all complaints, it will make the health plan an outlier in their submission for Part C and D reporting. By identifying and addressing all complaints systemically, the program will be improved, and complaints will decrease.

Use a System that Supports the Process – Gone are the days when grievances and appeals can be processed in a spreadsheet. The steps needed to adequately track, research, process, and communicate with members on the status of their grievance or appeal are regulated and time sensitive. Health plan staff needs software to manage the function, ensuring all steps are completed, and the correct tracking, trending, and reporting is completed. Without systems to support the process, the health plan is losing a valuable resource to improve the program.

Complete Root Cause Analysis – In order to fully utilize the information provided to a health plan by the complaint, the health plan needs to identify the root cause of the issue. “Root cause analysis” are overused buzz words, but the premise still remains true. Recently we worked with two health plans on a high volume of grievances about providers who members thought were in the network but were found to be non-participating providers. Investigation led to two different outcomes. One health plan found a broker agency was using the wrong product line selection when discussing provider status and thus enrolling members on inaccurate information. The second plan found there was an integrity issue in their provider directory information resulting in inconsistencies on which providers were truly contracted. Both had members enrolled under incorrect information, but the needed correction was very different. Without a root cause analysis, each individual issue could not be adequately addressed.

Resolve the Issue for All Impacted Members – Health plans are well versed in working with individual members to resolve his or her reported complaint. First-call resolution and greater authority and knowledge to assist members when they contact the health plan have resulted in better customer interactions. What suffers is the tracking of the issue as a complaint and, often, the resolution of the issue for other impacted members. My father had an issue with a denial on his Explanation of Benefits (EOB) for a hospitalization stating he might be responsible for a $36,000 hospital bill. My dad was planning on disenrolling from the plan over the issue. I assisted him in contacting the health plan involved. Customer Service researched the issue and identified it was due to a conflict between the hospital and the health plan over whether the service should have been an admission or an observation in the Emergency Room. The Customer Service representative was very helpful and assured us my father was not responsible for the charges as this was a covered event and would be resolved directly with the hospital. We were very satisfied with our interaction with the plan, but I couldn’t help wonder how many other members had the same scare my father experienced when he read his EOB. Would our call help prevent that? It is unlikely it would. This is the higher level on which health plans need to operate. Tracking and trending serves no purpose if the issue isn’t reviewed to determine what other members might be impacted and the issue corrected for them and future members.

Member experience is always important but even more so in the current competitive environment. Every day health plans receive gifts that identify the riptides in their organization which cause negative experiences for members. How many members end up in health plan riptides and disenroll or, worse yet, suffer physical or emotional harm for things previously communicated to the health plan? Valuing those gifts and training staff to identify the issue is the next step to move plans ahead and improve member experiences and, as a result, their quality of life. Health plans are always looking for a differentiators from their competitors. Managing complaints all the way through can be a great differentiating tool, and this one is already within grasp.

Gorman Health Group’s experienced Operations team can work with you to evaluate your program to identify opportunities to utilize the complaints you receive to improve your program. We also have CaseIQ™ , a software to process appeals and grievances in a compliant and efficient manner, including tracking and trending. We’ve been in your shoes and know your struggles and how to move beyond them. No one can change the past, but we all have the ability to influence our members’ future.



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Julie Billman

About Julie Billman

Julie Billman is Senior Vice President of Operational Performance & Provider Strategies at Gorman Health Group (GHG). In this role, health plans look to her to improve operational functions, maximize plan revenue, and educate plan staff to understand and own the Medicare requirements that govern their functions. Read more

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