Cogno-Solve

5 Ways to Tackle an Appeals Backlog

5 Ways to Tackle an Appeals Backlog

by Jim Bobeck

Government and commercial backlogs may occur quickly and without warning. A sudden spike of appeals can arise due to a seemingly innocuous change in government regulations. Adjustments to payment criteria for health services can send health plans, TPAs, ACOs, and PHOs into a claims tsunami. However, in most cases, backlogs mount gradually over time and are clearly foreseeable. Agencies and vendors find themselves stymied, without recourse, and lacking the internal resources to handle the workflow. While one could discuss ad nauseam the reasons why backlogs occur, the more challenging question is how to fix it. The following are short, yet helpful guidelines for any government agency or commercial vendor already “in the soup”:

  1. Dive Right In. If backlogs share anything in common, it’s usually this: the paperwork is a mess, and there’s literally cases piling up in dark corners of the office or in the darker areas of your computer case drives. Before any solution can be implemented, you need to know the extent of the problem. Backlogs can’t be fixed with the power of technology alone. There are no secret formulas. Instead, you need to diligently dive into the murk, assess the situation, determine whether the backlogged cases are intact or missing information, and figure out how they got there in the first place. In many cases, supervisors don’t know they have a backlog until they get a call from a customer, or an employee whispers in their ear that cases are piling up due some a glitch in their system.
  2. Seek Help and Contract Out Immediately. Don’t waste time trying to hire additional team members for a temporary problem or redesign your whole process to overcome the backlog. Instead, there are companies that thrive and live for inventory reduction projects, particularly when it comes to claims, appeals, applications, and eligibility decisions. These teams know exactly what to do and have proven and established experience that can provide immediate dividends.
  3. Create a Visibility System. Whether it’s using modern web-based products like Jira, legacy case  management systems, or plain old Excel spreadsheets, you need to create a clear tracking system that allows all team members to view the workload, assign work appropriately, and provide real-time, or at least daily, production updates. A visibility system allows you to plan your backlog attack, test solutions, monitor progress, make strategic adjustments, and continually improve the process. For ISO:9001 certified organizations, this process is well-known. Without a clear visibility system, it will be difficult to assess the problem and gauge progress towards a solution. Furthermore, you have stakeholders affected by your backlog, and you need a way to communicate with them clearly. Whether it’s a claimant, applicant, appellant, or third-party payer, these decisions affect people’s lives, and they deserve clarity.
  4. Build a Wall. Like any good backlog surgeon, you need to stop the bleeding before you can clean up the mess. Create a hard and fast wall between cases already in excess of their timelines for resolution, and all current cases that remain within timeliness standards for completion. Form two teams: one dedicated to the timely cases, and one solely dedicated to the backlog. The wall is an absolute fundamental. Without a clear demarcation line, cases will continue to move into backlog status, progress will be difficult to judge, timeliness metrics will continue to drop, and you will fail to stop the issue from reoccurring.
  5. Utilize Technology-Assisted Solutions. Most backlogs involve a high volume of cases with repetitious decision-making processes. Technology-assisted solutions can catalyze the decision-making process. Whether you automate the data gathering, extraction, and document organization processes or design ready-made templates that suggest a decision, there are technological solutions that amplify your inventory reduction projects by lowering costs and the number of people necessary to eliminate the problem. When choosing the
    right group and methodology to deliver results, ensure solutions are either technology-based or technology-assisted.