Spring Fever Focus: Grievances and Appeals

Spring is here, showing us all different signs of renewal.  It motivates us to clean out clutter, open those windows, and start the year fresh.  Audit season is also upon us, and people are taking a close, hard look at internal processes that surround grievances and appeals processing.  Findings in this area keep showing up, like that college grad that keeps popping in to visit his friends back on campus.  Just leave already, you’ve had your time!

What is causing the frequent failures that the Centers for Medicare & Medicaid Services (CMS) describes?  I spoke recently at the 2015 GHG Forum regarding this issue.  We believe it is one of the following factors: people, processes, or technology.  It’s time to perform an assessment on this area.  Ask yourself these questions:

  • How much specialized training has this team received this year?  How do I know our team leaders are up on the regulations and best practices?  Is the Grievances and Appeals (G&A) Department a dumping ground for service issues that could have been handled in Member Services?  With constant call center turnover, is G&A working closely with Member Services management to educate new staff?
  • Are procedures for case processing overly complicated? Is staff empowered to effectuate change, or are they hampered by rigid workflows?  Are the procedures even referenced anymore, or are they just a placeholder document for the intranet policy and procedure (P&P) library?
  • Can I customize our case database to meet my changing reporting needs?  Are the reports I am getting out of the system providing me with the information leadership needs to make decisions?  Are there steps in place to ensure all aspects of the case were completed?  Can it produce universes according to CMS audit specifications, or do I need to prep them manually?

These are tip-of-the-iceberg questions that we consider during an operational assessment of Complaints Tracking Module (CTM), grievances, and appeals processes.  As one of the highest risk, beneficiary-facing areas of your plan, this is a great place to kick off spring cleaning.  Create a checklist of your own to conduct an assessment of these processes.  Chances are, you already know your pain points, and you just haven’t documented and escalated as of yet.  Don’t wait until a CMS audit notice, as illustrated by a very truthful sentiment (thanks someecards!)



Gorman Health Group’s Complaints Tracking Module (CTM), grievances, and appeals processes, provides a new way to ensure your cases come to a timely and compliant resolution. Created with CMS in mind, as it captures key information related to intake, processing, categorization, determinations and higher appeals or re-openings to process cases according to CMS’ complex and detailed requirements. Contact us >>

Regan Pennypacker
Regan Pennypacker

Regan is Senior Vice President of Compliance Solutions at Gorman Health Group (GHG). She leads the Compliance Solutions practice, responsible for multidisciplinary projects such as Part C and Part D audits, new applications, marketing material reviews, risk assessments, and training engagements. As a member of this team, she has provided compliance direction and insight on industry best practices to many GHG clients. Regan brings GHG clients 19 years of experience in the healthcare industry. Read more

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