A Practical Guide to Modernizing Appeals & Grievances for Health Plans
Health plans are under mounting pressure to manage appeals and grievances not just to meet compliance mandates, but to reduce administrative burden, improve member satisfaction, and stay audit-ready. Yet many still treat the A&G function as a cost center, viewing it as a regulatory checkbox rather than a strategic opportunity. This mindset results in siloed systems, manual workflows, and little visibility into root causes or recurring issues.
But A&G isn’t just where complaints are resolved, it’s where trust is either earned or lost.
This ebook breaks down what it takes to modernize A&G, from building connected workflows and embedding compliance protocols to leveraging AI for faster case resolution and better reporting.
What you’ll learn
- Why most health plans treat A&G as a cost center, and why that needs to change
- How to automate audit readiness and reduce manual effort by up to 40%
- The operational and member experience value of root-cause analytics
- How GenAI and built-in compliance logic are transforming A&G case management
- Real-world outcomes from leading plans: fewer repeat grievances, faster audits, improved SLA performance
Who should read this?
- A&G and Compliance leaders
- Health plan Operations and CX teams
- Medicare, Medicaid, and Commercial plan executives
- Digital transformation, audit, and regulatory strategy stakeholders
Why this matters
For many health plans, A&G remains a compliance checkbox, draining resources without delivering strategic value. But that’s changing. Forward-looking payers are leading a wave of appeals and grievances modernization, transforming A&G into a source of operational insight, member experience improvement, and audit readiness.
Whether you’re rebuilding your program or refining what you have, this is your practical starting point.
Download the guide to modernize your appeals and grievances operations, and elevate them from a cost center to a strategic intelligence unit.