As a Medicare Advantage health plan, one of the main objectives should be to improve CMS Star Ratings. Why? Because the higher the ratings, the larger the bonus payments health plans receive from the government. This incentive exists to motivate health plans to improve their performance as it relates to disease management, preventive care and customer service.

Raising your health plan’s CMS Star Ratings is easier said than done. However, there are four major Appeals and Grievances (A&G) categories where you can improve member experience:

  1. Access Grievances
  2. General Grievances
  3. Fair and Timely Appeals
  4. Disloyal Members

Access Grievances

This category relates to how easy it is for members to get needed care (including care from specialists), appointments and prescription drugs through the plan. Specifically, you need to focus on the following measures:

Measure: C22

Getting Needed Care

Percent of the best possible score the plan earned, based on how easy it is for members to get needed care, including care from specialists.

Measure: C23

Getting Appointments and Care Quickly

Percent of the best possible score the plan earned, based on how quickly members get appointments and care.

Measure: D08

Getting Needed Prescription Drugs

Percent of the best possible score the plan earned, based on how easy it is for members to get the prescription drugs they need through the plan.

So how can one improve member experience in these areas? Here are a few quick-win steps to help you improve your health plan’s CMS Star Ratings:

  • Track and trend grievances related to access to care
  • See if you have issues with a particular provider or specialist by drilling down in your categories and subcategories
  • Understand your data so, if a particular provider needs to improve their access — or more specialists are needed for a specific specialty in your network — you have direction
  • Review your referral patterns, as the referrals may not be evenly distributed; you may have over-utilized or under-utilized providers resulting in access-related grievances

General Grievances

General grievances should never be overlooked. You need keep a watchful eye on the following measures:

Measure: C28

Complaints about the health plan

Percent of members filing complaints with Medicare about the health plan.

Measure: D04

Complaints about the Drug Plan

Percent of members filing complaints with Medicare about the drug plan.

Lowering these percentages is critical. To help drive down complaints, you should:

  • Track and trend grievances to determine the root causes
  • Establish standing meetings with cross-functional leaders to identify trends and improvement actions needed from each department
  • Implement improvements to address those issues (e.g., an updated training program to help ensure Member Services representatives deliver better member services)

Fair and Timely Appeals

How often does your health plan make timely appeal decisions? Does the reviewer agree with the denial of an appeal? What percentage of members fail to get a timely response to their appeal? To answer these important questions, you need to address the following measures:

Measure: C31

Plan Makes Timely Decisions about Appeals

Percent of plan members who got a timely response when they made an appeal request about a decision to refuse payment or coverage.

Measure: C32

Reviewing Appeals Decisions

How often an independent reviewer thought the health plan’s decision to deny an appeal was fair. This includes appeals made by plan members and out-of-network providers.

(Note: This rating is not based on how often the pion denies appeals but, rather, how fair the plan is when they deny an appeal)

Measure: D02

Appeals Auto-Forward

Percent of plan members who failed to get a timely response when they made an appeal request to the drug plan about a decision to refuse payment or coverage.

Measure: D03

Appeals Upheld

How often an independent reviewer thought the drug plan’s decision to deny an appeal was fair. This includes appeals made by plan members and out-of-network providers.

(Note: This rating is not based on how often the plan denies appeals, but rather how fair the plan is when they deny an appeal.)

Armed with this insight, what should you do about it? Here are some steps you can take:

  • Lower member effort and improve member experience by reducing the time to provide resolutions in all A&G cases
  • Add alerts, reminders and escalated notifications to your Appeals and Grievances system to ensure appeal decisions are timely
  • Establish regular Appeals Meetings with leaders of cross-functional groups and subject matter experts — including Medical Directors — to re-evaluate the accuracy of the decisions made, which are recorded in a comprehensive Appeals file (ideally housed in your A&G system)
  • Implement peer-to-peer processes to ensure expertise is utilized before making denial decisions (which should be captured in your A&G system)

Disloyal Members

Why do members leave your health plan and how can you prevent it? There are actually two measures that address member disenrollment:

Measure: C29

Members Choosing to Leave the Plan

Percent of plan members who chose to leave the plan.

Measure: D05

Members Choosing to Leave the Plan

Percent of plan members who chose to leave the plan.

So how can you minimize member disenrollment? Here are a few steps to take:

  • Develop a member callback program
  • Send out a questionnaire to find the cause of member’s exit from the plan
  • Identify the members who left the plan for one of the following two reasons
  • Voluntary disenrollment from plan
  • Disenrollment because of enrollment in another plan

Once you have Identified the disenrollment causes, you will be better equipped to implement tactics that will help improve member loyalty.

If you would like to learn more about what types of strategies and tactics you should consider to sustain a world-class Appeals and Grievances department, one that can help improve your health plan’s CMS Star Ratings, we invite you to download our free eBook today.