Virtusa Appeals and Grievance (A&G) Solution

Servicing Appeals and Grievances(A&G) is a daunting task for the payer organizations. With increased regulatory oversight from CMS and DOH Payers are at extreme urgency to optimize and improve their A&G servicing. Currently, A&G servicing process faces lot of limitations due to legacy systems, broken business process and heavily manual functions happening across various levels during appeal servicing. To improve member satisfaction and retain increased CMS Star ratings Plays must service the appeals within the Stipulated Service Level Agreements (SLAs), handle the member/Provider Correspondences on time and with Accuracy and disposition the appeals well according to the Org/Fed/State Regulations and Policies. 

To help Payers navigate this business problem, Virtusa has developed the Appeals and Grievances(A&G) solutions Accelerator. The A&G Accelerator enables the Payer Orgs to update and upgrade their current A&G ecosystem by offering:

• Technology-enabled business processes ensure adherence to all CMS and DOH guidelines and audit-ready accessibility of data
• Reduce inefficiencies & Increase accountability by unifying business workflows & Integration with enterprise systems
• Significantly improve member/provider satisfaction through early root cause identification & Prompt determination
• Potential to avoid high CMS penalties annually by doing data validation upfront & by Embedding key cleansing rules as part of case workflow
• Processes that enable the knowledge of case management to be easily referenced, documented and transferrable

• Dynamic Portal and Digital Dashboard for the Case Coordinator
• Intelligent Workflow to capture and assign appropriate task for each appeal and grievance
• Smart Adapters to connect/consume the appropriate data from required source of record
• Parent-child relationship of complaints with A&G
• Generate interactive acknowledgement correspondence using case parameters
• Trigger acknowledgment correspondence using preferred channel (mail/email/fax)
• Decision-making capabilities for RN for pre- and post-service appeals
• AI-powered decision recommendations for RN
• Appropriate routing to MD for escalated decisioning
• Decision-making capabilities for MD for pre- and post-service appeals
• Linkage of the prior level appeals for end-to-end tracking and faster resolution