Grievance Management

Healthcare organizations establish Compliance Departments with the primary purpose of providing compliance oversight for the organization. Operational teams—such as the Member Services Department and the Appeals & Grievances Department—have significant compliance regulations, so they must know to maintain compliance. This includes CMS regulations for Medicare Plans, regulations for Commercial Plans and Medicaid regulations for state plans. A grievance management software with latest regulatory compliance rules built-in can help healthcare organizations in properly classifying grievances and improve member experience.

Within those regulations, there are requirements around grievance classifications. This is not only to ensure the case is routed and handled properly, but also to accurately report the grievances to the regulators. One of the biggest challenges leaders of the Member Services and the Appeals and Grievances Departments face is the proper classification of grievances.

This blog will provide high-level guidance on how to embed best practices into your Appeals and Grievances system to improve grievance classifications. And there are key steps a healthcare organization must go through to establish a best-practice approach.

Determine → Define → Dependency → Dynamic → Display

1. Determine the grievance categories using a Grievance management system

The first step is to read all the required regulatory reports for Appeals & Grievances. Then, determine which grievance categories and subcategories are mandatory to fulfil the reporting requirements. Finally, ensure your list is comprehensive for all reports. Most reports will be very specific and tell you exactly which categories you are required to include in the report.

With this in mind, much as possible, find a way to standardize grievance categories so that they can equally apply to CMS reporting, Medicaid reporting and Commercial reporting. By standardizing your list of grievance categories, it will help improve the training and retention.

For example, in the CMS Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, it outlines different grievances in Section 30:

  • Grievances may include the following:
    • An enrollee’s involuntary disenrollment initiated by the plan
    • A change in premiums or cost sharing arrangements from one contract year to the next
    • Lack of quality of the care received
    • Plan benefit design
    • Difficulty contacting the plan via phone
    • Interpersonal aspects of care
    • The appeals process
    • The plan’s decision not to expedite a coverage or appeal request
    • General dissatisfaction about a co-payment amount, but not a dispute about the amount the enrollee paid or is billed
    • General issue about a drug not being on the formulary or listed as an excluded drug
    • Calculation of True Out-of-Pocket (TrOOP) costs

Please note: Both NCQA and URAC standards also have their own respective grievance categories that they would like reporting on. There will be some overlap but, if the healthcare organization is also adhering to these standards, it is important their grievance categories are also captured.

All the grievance categories should be pulled together into one lengthy list. If there are any unique categories that only apply to one line of business, then there should be an indicator so it can be filtered out for the other line of businesses that don’t apply.

2. Define grievance category

It’s important to start with defining each category/subcategory combination. Preferably, it will align with regulatory definitions. For example:

  • Category: Quality of Care
    • Subcategory: Inappropriate Primary Care
    • Definition: The member is upset about medical treatment provided by their Primary Care Provider
  • Category: Access
    • Subcategory: Appointment Schedule Time
    • Definition: The member is upset about waiting too long to set up an appointment with a PCP or Specialist

A quality-of-care grievance is a type of grievance that is related to whether the quality of covered services provided by a plan or provider meets professionally recognized standards of health care.

Examples of a quality-of-care grievance include any instances where an enrollee infers or states they believe:

  • They were misdiagnosed
  • Treatment was not appropriate
  • They received, or did not receive, care that adversely impacted or had the potential to adversely impact their health

After you create a standard list of grievances with their respective definitions, you could have them auto-populate in the Appeals & Grievances system (after a grievance is selected).

The field that holds the definition is like a quick “Help” button. The definition then can be compared to the Description of the Grievance field to determine if the grievance category is accurate.

3. Dependency

When selecting a category, ensure your Appeals & Grievances management System only provides the related Subcategories, not all of them. This will reduce the number of errors in your regulatory reports.

This step is critical. It is usually not enough to simply have a list of grievances. They often aren’t defined enough to determine precisely which path to resolve a member grievance.

For example:

  • A member complained about not having access-to-care issues while setting up a primary care appointment within 10 days
  • The member also complained about not having access to care issues with a cardiologist.

They are both access-to-care issues. However, they are different.

The first access-to-care issue is related to Primary Care and the second access-to-care issue is related to Specialist Care. The subcategories will allow for further distinction, which will help streamline the resolution process and give rise to more detailed reporting.

4. Dynamic

When a Category and Subcategory combination is selected in the Grievance Workflow Classification step, as mentioned previously, the definition should appear in the step. This will help the Appeals & Grievances management professional to determine if the grievance being selected aligns with the initial Grievance Description in the Intake Grievance step. This will also reduce the number of misclassification errors.

5. Display

In another field, display the reporting value in read only. The report will be mapped to this read only field. This will help ensure that the report will only have values it is expecting and this will eliminate manual mistakes.

An example of this is related to the CMS Quarterly Reports. There are specific CMS grievance categories required to populate this report. Relationships need to be set up between the grievance categories, subcategories and CMS grievance Categories. Once these relationships are established, after a grievance category and subcategory are selected, the CMS Grievance Category field will auto-populate with the relevant CMS Grievance Category.

Following these steps, and embedding these best practices into your Appeals & Grievances management system, will help:

  • Increase grievance classification knowledge across the team
  • Decrease the grievance resolution turnaround times
  • Improve the regulatory reporting

Inovaare has been delivering a compliance-driven Appeals and Grievances management platform to healthcare organizations since 2008. We can work with your organization to uplift your technology suite to ensure you are following all the right steps and complying with all regulatory guidelines, including those related to Appeals and Grievances. Please contact us to explore how we may be able to support your healthcare organization’s compliance processes!

For more details, please contact us at or 408-850-2235