Appeals and Grievances
We have worked with many of the leading payers and providers in the healthcare market.
Recent regulatory reforms have led to increased enrollment for Healthcare and Medicare coverage and enhanced member rights, causing a steep rise in Appeals & Grievances. Customized provider contracts that govern case specific Service Level Agreements (SLAs) require close scrutiny for accurate resolutions, making the process extremely cumbersome and time- consuming. Healthcare payers and providers have realized the importance of creating faster and more efficient Appeals and Grievances management processes for improving customer satisfaction. Technology can act as an enabler by creating process flows that drive customer satisfaction, while improving productivity and reducing the overall cost of their services.
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Our Appeals, and Grievances (A&G) management solution delivers robust functionality across the length and breadth of the solution. It provides a business configurable process automation and improvement framework that allows timely resolution of Appeals & Grievances received in any form – email, paper, mail, customer service, web portal, walk-ins, fax, electronic documents etc. The smart rules driven engine prioritizes all transactions for automated routing, ensuring resource optimization, and reduced TATs. It guarantees enhanced customer satisfaction through a robust correspondence management system that initiates appropriate communications at various stages of the process.
The solution suite is a comprehensive and unified Appeals and Grievances platform that helps you engender collaborative synergies between providers and members by bringing together the power of 4 Cs –
- Automated capture of critical documents such as signature forms, physician reports, etc
- Storage of attachments, member, provider, claims, and authorization data within the case
- Secure vault of case documents with access and audit driven rights
- Rules based routing and redirection of files
- Version controlled repository of member documents
- Seamless intake of data across multiple channels
- Automated due date calculations, decisions, validations and case prioritization
- Skill based, role based and case based routing of cases
- Manage escalations with real time alerts and reporting dashboards
- Removes process bottlenecks and creates a process improvement culture
- HIPAA Compliance is met as all access to PHI is secured
- Role-based, secure access to systems, information, and documents
- Real time reports on document changes along with timestamps
- Extensive audit trail with detailed, long-term record for every case
- Automated selection of letter templates with pre-populated information
- Guided procedures with best-practice-based templates
- End-to-end process visibility with real time analytics
- Real-time acknowledgment, notifications & status updates to appellants
Contract Lifecycle Management
A lot of organizations manage their contracts via inefficient, manual and silo-ed processes. This can lead to long turnaround times, inaccuracies and added expense. Our Contract Management solution helps streamline, standardize and automate contract initiation, creation, versioning, negotiation, execution through to expiration. It provides:
- Central Repository (or integrate to an existing one) and sophisticated search engine
- Workflows for routing, escalation, alerts and deadlines
- Privileges for viewing or editing
- Accessible via tablet or smartphone
- Reports and audit trail
It helps reduce contract cycle times by 80% with improved control, standardization and visibility for all contracts across the organization. This leads to lower administration costs, improved compliance, increased revenue, lower risk and an overall gain in employee productivity.
Key Features of Contract Lifecycle Management Solution
- Automate contract process – Design the Contract Management process including contract authoring, review, contract registration, contract renewal, contract termination and request for addendum to the contract.
- Escalation capability – Import Escalation Matrix from the customer’s active directory automatically through integration and then used to define escalation structure.
- Reporting and compliance – Create standardized reports using Report Generation Wizard and obtain contract compliance data from Newgen OmniFlow & Newgen OmniCompliance
- Data Management – Store and manage data centrally with easy data accessibility
Key Benefits of Contract Lifecycle Management Solution
- Ensure accountability – Creates readily available record of contracting actions, makes it easy to track results from public expenditures and ensures that payment is commensurate with performance.
- Optimize contract management -Fast track contract generation and reduce risk by implementing enterprise standards and policies that govern their use. Identifies any major gaps – key contracts that may have expired – and major risks.
- Gain 360 degree visibility – All contracts are stored centrally ensuring easy accessibility. Comply with your contractual obligations through close tracking of performance and payment obligations. Eliminate revenue leaks, avoid compliance failures and contractual disputes.
- Analyze your contracts – Discover hidden weaknesses that are undermining the performance of your business, or that will cost you dearly during a crisis.
- Reduce documentation dependency – Draft, approval, negotiation and signing of contractual documents made easy through process optimization.
Provider Contract Management
Too many Health Plan Payers still work in silos when it comes to Provider Contracting, Credentialing, Configuration, and Communication. Newgen’s Provider Contract Management Software is the only solution that automates and integrates all of these functions on one platform. Built on an advanced Enterprise Content Management (ECM) and Business Process Management (BPM) system, the solution delivers speed and accuracy across the contract lifecycle.
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The Provider Contract Management solution creates a centralized repository of contract information and provides business user with role-based access to sensitive contract data and documents. It then orchestrates this information across departments using an advanced workflow engine that automates critical business processes.
Contract Creation and Archival
Sales executives with minimal legal experience need to be empowered with smart tools to drive value driven contracts with closely monitored SLAs. Provider Contract Manager provides an automated, self-service environment for business users with minimal contract experience to draft agreements. Guided authoring tools ensure consistency and accuracy, shortening the negotiation cycles and minimizing legal risks. All negotiations and re-negotiations are taken care of by the system through real-time stakeholder collaboration and robust document versioning.
Credentialing for all providers is a key compliance imperative. This can however be complex and time-consuming due to the multi-level checks prescribed by various regulatory bodies. Provider Contract Manager comes with an advanced workflow that manages the provider credentialing in a sequential and organized manner. Cases are auto-routed to resources when the system finds a match between the user profiles and the applicable state laws. Users can work on an pre-configured, intuitive checklist that we have built using our rich domain knowledge, to make sure there are no slip-ups.
Configuration is a complex process which requires careful aggregation and auditing of provider information that includes their demographic, institutional, professional and financial details. It also involves extensive documentation and data entry work which can result in numerous operational errors. Provider Contract Manager streamlines the entire configuration process, from Case Initiation to Provider Loading and generation of correspondence letters. All approvals and rejections are managed through a structured and automated review process.
Providers need to be constantly apprised of the changing contract dynamics. They must also be reminded of any missing information to complete the provider configuration. Provider Contract Manager ensures timely and automated provider communications through event based triggers. For instance, in case the provider is terminated from the already existing contract, the members are re-assigned to another Provider and both parties are informed of the same. Similarly, on completion of the provider configuration, welcome letters are generated without any delay due to manual handling of work.
Reporting and Monitoring
Contracting process needs to be mapped end-to-end to ensure compliance adherence and resource productivity. Provider Contract Manager is built on a world class BPM platform that provide advanced tools for real-time process monitoring and performance management. Business users have a unified dashboard where they can view various aspects across the contracting lifecycle.