Abstract

This IDC Perspective outlines the context, requirements, solutions, and vendors executed by payers to address this growing transaction in the health ecosystem.

"Although the appeals and grievances payer function has been historically internally cobbled together, there are now all-encompassing technologies that provide the rigor that CMS demands," says Jeff Rivkin, research director at IDC Health Insights. "No one internal payer organization really 'owns' appeals and grievances so, like most hybrid, multifunction spaces, the resultant processes and software are internally fragmented. Consumerism and CMS have now demanded that industrial strength software and processes exist in all Medicare Advantage Plans, and commercial plans are following suit. We now have the means and motivations to address this emotional member transaction that exemplifies the pain caused in the fragmented healthcare/payer environment."

Coverage