Complaints, Appeals & Grievances (CAG / ANG) in Healthcare

Complaints, Appeals & Grievances (CAG / ANG) in Healthcare

Business & Technology Perspectives for Payers and Providers
 

Complaints, Appeals, and Grievances (CAG / ANG) systems are mission-critical in healthcare. They drive compliance, member satisfaction, and financial outcomes. For Payers (P1), they ensure CMS and NCQA compliance, and for Providers (P2), they help resolve denials and patient issues effectively.
 

Why CAG Modernization Matters
 

• - Rising complaints and appeals volumes across Medicare, Medicaid, and Commercial LOBs
• - Risk of SLA breaches, audit penalties, and poor member experiences
• - Legacy systems lack AI, automation, and integration capabilities
• - Modern CAG ensures regulatory compliance, operational efficiency, and strategic insights

Business Use Cases for Payers (P1)

• - Medical Appeals – Nurse/MD clinical review with SLA-based timers
• - Pharmacy Appeals – Drug formulary & prior authorization disputes
• - CMS Complaints Tracking (CTM) – Direct integration with Medicare portal
• - Provider Disputes & Payment Challenges – Contractual underpayments & out-of-network disputes
• - Regulatory Universes – CDAG, ODAG, NCQA, Article 44/49 reporting
• - Fraud, Waste, Abuse (FWA) Investigations – Complaint-triggered SIU workflows

Business Use Cases for Providers (P2)

• - Patient Complaints – Billing errors, treatment dissatisfaction, access issues
• - Denial Appeals – Claim resubmissions with supporting medical documentation
• - Clinical Quality Issues – PQIs, safety events, quality of care complaints
• - External Inquiries – Regulatory/legal escalations
• - Revenue Insights – Identifying payer denial patterns for process improvement

Technology & Platform Capabilities

• - API-driven integrations with claims, auth, CRM, and CTM systems
• - AI/ML for triage, predictive analytics, and GenAI for summarization of clinical data
• - Automated intake (fax, email, portal, phone), SLA tracking, and escalation rules
• - Omni-channel communication – letters, SMS, email, portal notifications
• - CMS/NCQA audit universes, real-time dashboards, and compliance alerts

Example Workflow: Appeal Case Lifecycle

• - Intake – Claim denial appeal received and categorized
• - Enrichment – Auto-fetch claim/member/provider data via APIs
• - Triage – AI routes to correct team based on urgency and LOB
• - Clinical Review – Nurse/MD assisted by GenAI clinical summaries
• - Resolution – Case routed to claims for effectuation and outcome applied
• - Communication – Letters/emails auto-generated with member’s preference
• - Compliance Closure – Case validated, reported to CMS universes

Business Value & ROI

• - 215% faster case processing across all LOBs
• - 242% faster audit reporting with pre-configured CMS universes
• - 340% improved compliance and SLA adherence
• - 3:1 ROI with payback in less than 6 months
• - Improved Stars ratings, NCQA scores, and member/provider retention

GHIT Digital’s Role

• - Platform evaluation and vendor selection (NewgenONE, HealthEdge, MHK, etc.)
• - API integration with EHR, CTM, claims, and CRM systems
• - Low-code customization for Medicare, Medicaid, FEHB, and Commercial LOBs
• - Pre-configured regulatory universes and audit-ready reporting
• - Managed services for upgrades, SLA monitoring, and analytics enablement

Q&A Section

1. Q1. Why replace our legacy system?

A1. Legacy tools lack AI, low-code agility, and audit readiness.
 

1. Q2. How do you ensure compliance?

A2. SLA timers, escalation rules, and CMS/NCQA universes.
 

1. Q3. How does GenAI help?

A3. Summarizes medical records, auto-generates letters, and predicts outcomes.
 

1. Q4. How does this benefit Providers?

A4. Faster denial overturns, reduced AR days, and trend insights.
 

Conclusion
 

CAG/ANG modernization is essential for regulatory compliance, operational efficiency, and member/provider trust. With AI-powered, low-code platforms like NewgenONE and GHIT Digital’s implementation expertise, healthcare organizations can transform complaints and appeals into a compliance engine, experience enhancer, and intelligence hub.
 

MonMass, Inc. (the legal name of GHIT Digital) will work on your strategic IT Projects or tactical Staffing & Consulting requirements (NAICS codes 541511 / 541512 / 541330 / 541618). Feel free to call 201.792.8924 or write to us at Contact@GHIT.digital for no obligation discovery conversation. You are welcome to share your RFPs/RPQs for us to review and respond on time.

• - Monika Vashishtha, MBA I President      Monika@GHIT.digital  I   646.734.6482
• - Sharique Nisar, MBA I CMO                     Sharique@GHIT.digital I 201.792.8924
• - Som Sharma, BTech I CPO                      Som@GHIT.digital I     201.792.8924
• - Contact GHIT at:                                       Contact@GHIT.digital  I Careers@GHIT.digital

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