This article is part of an ongoing series highlighting different teams across VNSNY. Our aim in running this series is to enhance the VNSNY employee experience by spotlighting all parts of VNSNY, revealing things you may not know about another team, and bringing our organization closer together. If you know of a VNSNY team that you think should be included in this series, please let us know by clicking here!
The CHOICE Grievance and Appeals Team addresses and resolves member and provider complaints and appeals for VNSNY CHOICE Health Plans. Read on to learn more!
- Grievances and appeals are not the same thing.
One of the most common misconceptions about grievances and appeals is that they’re one and the same. Although both involve resolving member (and provider) complaints and appeals, the process is different for each. “An appeal involves a denial of a service or a benefit, and is a formal way of asking us to review information and change our decision on a coverage determination we’ve made,” explains Tanya McCray, Vice President, Grievance and Appeals, CHOICE. “A grievance is any expression of dissatisfaction other than one that involves a coverage determination.”
- The department handles 10,000 to 12,000 cases a year.
The Grievance and Appeals Team’s role is to improve the experience for CHOICE plan members and serve as a clearinghouse for issue resolution. To handle its sizable caseload, the team has 29 full-time employees, including dedicated nurses and non-clinical staff.
- Grievances involve proactive customer care.
A grievance is a general complaint: Maybe a plan of care doesn’t reflect what the member thinks it should be, or a home health aide was late. Or the grievance could involve transportation that doesn’t show up on time, dissatisfaction with call-center wait times, or issues with durable medical equipment deliveries. There’s a strong customer-service aspect to grievances—in fact, many grievance calls are escalated calls forwarded by the CHOICE customer service representative team. “For a grievance, we’ll reach out to the those in question to get to the bottom of the issue,” says Tanya. “We’ll find out whether it’s a one-off problem or more of a systemic issue. Once we have the information, we’ll contact the member and walk them through what happened, providing them with an explanation and, a written resolution.”
- Appeals involve a careful, collaborative team review.
Nurses on the Grievance and Appeals Team are responsible for reviewing the details of each appeal and for making recommendations on how to respond, working directly with consulting medical directors who sign off on all appeal decisions. “My team is responsible for ensuring that all issues are carefully investigated on an individual basis, and decisions are made that are not only in the best interest of the patient but of the plan as well,” says Tanya. “We are not always going to agree with the member or provider—sometimes it’s a matter of managing expectations—but we always aim to satisfy the issue within a specific time frame. The average turnaround time for an appeal is 72 hours.”
- The lower the appeals overturn rate, the better!
Even though it might sound counterintuitive, a low overturn rate for appeals is actually a terrific testament to a health plan. “We aim for an overturn rate of less than 40%, and we’re proud to be well below that at 27%,” says Tanya. “That means we’re making the right decisions at the initial denial phase. If an insurance company grants a high percentage of appeal approvals, it usually indicates that there’s something inherently wrong with its initial system or process. If you make a careful determination to begin with, you don’t have to ‘correct’ it with an appeal.”
- Grievance and Appeals is a valuable indicator of how CHOICE is doing overall.
“You can tell how well a company is doing based on how many grievances and appeals you get,” notes Tanya. “We have a terrific automated database that tracks everything coming through our department. If we find a hole in the system or see a trend, we’ll generate a report to spotlight it.” says Tanya. “Our team is dedicated to the organization and to its mission. We want every team to succeed, and we encourage anyone to ask us for help. We’re always willing to jump in and participate!”
To read similar articles in the series on other teams in the organization, click here.