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HEALTHCARE

Automating the Appeals and Grievance Process

The Challenge

El Paso First Health Plans, a non-profit health plan serving El Paso and Hudspeth counties in Texas, wanted to replace its cumbersome, manual-based appeals and grievance procedures with an automated solution. Because the organization’s state mandated deliverables were all completed by hand, internal routing meant walking each paper case to the next department. As volumes increased and with several years’ worth of paper cases on file, the manual process was no longer feasible.

Our Approach

To maintain compliance, reduce costs and increase efficiency, El Paso First Health Plans licensed the TriZetto QNXT Appeals and Grievance Workflow solution from Cognizant. The new software allowed the plan to create business rules that combine CMS and Affordable Care Act regulatory requirements with internal business processes and establish new customized workflows. Instead of a spreadsheet, the health plan now has a central repository for all appeals, grievances and complaints with access to related member, provider, claims and authorization information.

Big Productivity Increase Saves Time and Money

As soon as the system went live, El Paso First Health Plans began reaping the benefits of its new automated solution. The time required for new case creation, routing and research has decreased significantly, staff overtime has been eliminated and operational and state report generation is now fully automated.

The health plan now has a full automated, centralized process for appeals and grievances that is saving it time, money and effort. With a 50% increase in productivity for the plan’s Complaints and Appeals specialists, El Paso First Health Plans has eliminated staff overtime requirements, and investigation response time has been reduced by 75%.

100%

percentage of workflows now automated for the appeals and grievance process

75%

reduction in investigation response time

50%

increase in Complaints and Appeals Specialist productivity

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