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| 4 minutes read

Resolution of Grievances: Using a Broader Lens

Let’s face it, most grievances are not simply a point in time or involve a singular topic. Often, they are the opposite. Grievances are multifaceted and contain compounding issues requiring an employee to use a broad lens to thoroughly comprehend the reasons behind the beneficiary’s grievance. Assessments are hardly straightforward, and staff need a complete grasp of how the entire Medicare benefit impacts that beneficiary throughout the plan year and the interconnections of clinical inputs, financial responsibilities, coverage decisions, and regulatory requirements to provide a comprehensive explanation to the beneficiary when providing a resolution response. 

Chances are your grievance department has operational responsibility to intake beneficiary grievances, research and query the complaint, and close the case by providing written and/or verbal resolution to the beneficiary. They rely on many internal partnerships (from areas such as medical affairs, utilization management, provider networks, and customer service) to perform research and gather information from across your healthcare organization. Meanwhile, they also require assistance from external partners (First Tier, Downstream or Related Entity (FDR)) to assist with testimony regarding beneficiary-specific grievance scenarios. These external partners could be your Pharmacy Benefit Manager (PBM), a network hospital, or a marketing agent. This puts the grievance department in a position that requires coordination across multiple areas to assemble the case and comprehend how all this information needs to be compiled to resolve the beneficiary’s grievance. Considering the vast number of contributors to grievance resolutions weighs heavily on the grievance department to convert this information into a resolution response to the beneficiary in simple terms. Thereby, emphasizing the importance that grievance departments understand Medicare Part A, B, and D policy, delivery mechanisms, financial practices, benefit designs, business processes, and how the fundamentals of each of these areas influence the outcome in totality.

Ankura’s Perspectives

Application. As we have discussed, grievances are complex and multi-faceted. Grievances have many divergent pathways and can often take on multiple topics at once, creating confounding parameters that need to be considered and evaluated. This requires staff to exercise problem-solving skills, possess knowledge across regulatory and operational areas, and coordinate cross-functionally to troubleshoot unfamiliar topics to adequately provide resolution responses. Therefore, staff handling grievances should be trained to comprehend the delivery models of the Medicare benefit and enhance their skillset beyond fundamental compliance requirements. 

Ankura Observations. Most employees in Grievance Departments have the fundamental knowledge regarding turn-around times, expedited grievances, applicable extensions, identification of Quality of Care, and when to provide written and/or oral resolutions. However, the depth of knowledge varies across employees surrounding the ability to comprehend the depths and delivery of the Medicare benefit. Organizations often focus on training grievance staff to meet compliance obligations and process grievances according to internal procedures; however, they do not always provide training surrounding the application of the Medicare benefits and apply this information in communications to beneficiaries to solve their grievance(s). Training needs to stretch beyond the Part C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeal Guidance and enhance trainings encompassing benefit/financial calculations, provider/pharmacy networks, formulary designs, utilization management, and other delivery channels that plan sponsors view as common grievance sources. 

Composition. Grievances are difficult. Most often the results of all research are measured upon the completeness and accuracy of the grievance resolution response. However, attributed to some of the complexities of grievances, they are required to be researched and documented by operational areas beyond the scope (or knowledge base) of the Grievance Department. Sometimes this requires specialized knowledge and may be best communicated by a subject matter expert in this specific area. 

Ankura Observations. Some grievances are related to rare circumstances or entail a thorough understanding of a concept (e.g., benefit design, provider networks) to provide an adequate response. Consequently, the task to communicate this response to a beneficiary is assigned to an employee who is not best suited to convey this message. Organizations should deploy the best subject matter resource(s) to compose or collaborate cross-functionally to produce the response ensuring that the complexities are addressed in a manner that accurately addresses the beneficiary’s grievance. Ankura has often seen where subject matter experts provide adequate response to an internal inquiry received by the Grievance Department, however, this message is lost when attempted to be communicated to the beneficiary via written or verbal resolution by an employee who does not have full comprehension of the scenario. As a result, the beneficiary receives an inaccurate resolution response.        

Templates. Templated language allows for efficiency and consistency from an operational standpoint. Comprehension by staff performing resolution responses must understand how these templated responses can be interpreted and when they are suitable. When used incorrectly, templated language can lead to the proverbial square peg in the round hole, causing greater beneficiary confusion and creating audit risks because of inaccurate responses.   

Ankura Observations. In review of sample grievance resolution letters, Ankura observes that the use of templated language often introduces information that did not pertain to the beneficiary specific scenario or did not provide an adequate explanation to their grievance. Grievances are often non-linear and make use of templated language difficult because fixed language will respond to a specific type of grievance. Templated language can be foundational to assist with the efficiency in providing a resolution response, but staff needs to achieve a level of autonomy and ability to modify language to fit the specific message necessary to be communicated to the beneficiary. 

© Copyright 2021. The views expressed herein are those of the author(s) and not necessarily the views of Ankura Consulting Group, LLC., its management, its subsidiaries, its affiliates, or its other professionals. Ankura is not a law firm and cannot provide legal advice.


healthcare & life sciences, healthcare compliance, memo, f-risk, compliance

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