Medecision Launches Integrated Solution to Simplify Appeals and Grievances Processes for Health Plans Serving Government Populations

James Coates James Coates
Vice President, Marketing Services

Aerial™ Appeals and Grievances to help plans with Medicare Advantage, Medicaid & dual eligible beneficiaries improve compliance, minimize penalties & improve quality scores

DALLAS, TX – May 1, 2018, Medecision, the leader in population health management solutions for risk-bearing entities, announced today it has launched AerialTM Appeals and Grievances, which will enable health plans, particularly those serving Medicare Advantage, Medicaid and dual eligible populations, to streamline these processes. The integrated solution allows plans to better monitor, track and manage appeals and grievances to more easily comply with complex regulations and specifications, improve STAR ratings and enhance member satisfaction and loyalty, ultimately ensuring better coverage for beneficiaries.

The Centers for Medicare & Medicaid Services (CMS) is projecting it will issue health plans $42 to $60 million in appeals and grievances penalties this year due in part to plans’ poor appeals procedures and tools that create delays and data quality challenges. Medecision’s Appeals and Grievances application, which interfaces with its robust SaaS platform, including its utilization and care management solutions, enables plans to automate and standardize appeals and grievances. It centralizes information from disparate data sources to help plans proactively meet CMS’s complex specifications and ensure audit readiness and timely compliance for protected revenue and improved STAR ratings.

“Approximately 40% of the factors in STAR ratings can be tied to appeals and grievances operations, meaning health plans have a significant opportunity to drive the management and growth of a network just from improving these processes,” said Deborah M. Gage, president and CEO, Medecision. “By doing this, plans can better protect revenue, drive efficiency and bolster member satisfaction. Moreover, we estimate the average government plan serving 150,000 members stands to reduce labor costs by 30% and save $.50 per appeal, per member, per year.”

Aerial Appeals and Grievances helps health plans with government populations better manage the clinical and financial performance of these businesses by:

  • Integrating data from disparate sources, allowing external review of appeals, and reporting on appeals and grievances determinations
  • Helping adhere to strict review timelines
  • Driving higher revenue with quality bonuses and avoiding enforcement actions for noncompliance
  • Gaining visibility into which providers have the highest and lowest grievance levels to manage network performance
  • Reducing disenrollment and associated new customer acquisition costs
  • Real time compliance and monitoring to check Star Ratings progress and remove lower quality services to strengthen ratings and ensure compliance — optimizing 2 of 5 Star Rating factors

To learn more about how to achieve a stronger network and meet CMS compliance requirements by managing appeals and grievances, read our blog post on CMS’ industry-wide monitoring project, and subscribe to our blog to receive timely and relevant industry insights.


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