Pegasystems' SmartBPM® solution framework for healthcare organizations automates the member-complaint management process by providing speedy resolution, consistency, regulatory compliance, and customer satisfaction.

Efficient management of member complaints poses an administrative challenge for many healthcare organizations. Regulatory and contractual obligations differ by impacted party and line of business. Timely case resolution requires data collection and input from diverse parties and technical systems. Non-compliance and procedural inaccuracies have significant monetary implications.

Built expressly for healthcare organizations, Pegasystems' Appeals and Grievance Manager™ is a packaged, scalable solution that automates and optimizes member complaint management. Built on PegaRULES Process Commander®, a Business Process Management (BPM) system with a built-in rules engine, the framework provides a solution that automates the healthcare-complaint process from case creation through resolution. It can be rapidly deployed and easily extended throughout a healthcare organization.

Appeals and Grievance Manager addresses significant complaint-management challenges faced by all healthcare organizations:

• Stringent, continuously changing regulatory requirements that vary by line of business and geography, mandating strict controls over processing times, correspondence, and reports
• Difficulty collecting and documenting supporting information from disparate sources — each of which may need to provide input simultaneously within very short timeframes
• High financial risk and negative public exposure from mismanaged complaint cases that can seriously hinder membership growth and retention
• Inefficient, manual complaint processing with inadequate reporting capabilities that prevent the identification of root causes and the creation of viable solutions

Key Benefits

By capturing business objectives, optimizing processes, and driving work to completion, Appeals and Grievance Manager delivers the necessary agility for:

• Productivity — Straight-through complaint resolution, correspondence automation, and guided processing increase consistency and reduce manual work.
• Growth— Timely and consistent complaint resolution drives customer and provider satisfaction. Accurate reporting at multiple levels enables analysis of trends and of ongoing service and benefit improvements.
• Compliance— Automating service-level agreements, controlling use of approved correspondence, providing unalterable audit trails to document-processing steps, and storing full documentation (including case-based attachments) ensures compliance with complex regulatory and customer-specific regulations. Standard reports and an intuitive custom report wizard support documentation of compliance activities.

The Solution

Appeals and Grievance Manager includes 15 packaged best-practice complaint workflows, a library of standard correspondence templates, over 400 defined rules, and a set of representative, healthcare-specific user portals. It can be implemented as part of an organization's customer-relationship management initiative, or as a standalone solution.

Other important features include:

• Directed Web access for external users
• Service levels
• Routing, prioritization, and escalation
• Quality-improvement audit
• Support for member self-service portals
• Correspondence generation
• Customized and standard reports
• Connectors to external systems

Familiar Visio tools make it easy to maximize the power of Business Process Management. Users can personalize and extend any of the packaged complaint workflows, or create entirely new ones.

Key Functionality

• Processes complaint via the phone, Web, email, or paper with electronic storage of the original paper request or fax images
• Appeals and Grievance Manager delivers core complaint management functionality:
  • Validates requestor information and automates retrieval of relevant information (demographic, eligibility, claim, authorization, etc.) from multiple systems
  • Automates business-policy rules for straight-through processing, such as automatic resolution of appeals under specified dollar thresholds and system-generated correspondence and party notification
  • Creates and manages multiple, simultaneous assignments to internal and external parties
  • Assigns work based on case type, business segment, or phase in the process
  • Monitors goals and deadlines for procedural, contractual, and regulatory compliance
  • Automates escalation processes by generating reminder correspondence, increasing case priorities, and routing to appropriate individuals who are authorized to move work to completion
  • Provides automated and on-demand correspondence generation to ensure use of approved materials
  • Maintains correspondence within the case and audit trail as an official part of a complaint record
  • Tracks and reports information to all required parties