Using Interim Staffing to bring Appeals and Grievances Timeliness into Compliance–A Case Study

Sometimes, life happens. Turnover, volume increases, changing guidance, system changes or audit issues that require remediation all can create situations where a Plan or PBM needs expert resources fast.  And let’s face it: good resources with expertise in government-sponsored health care are hard to find.

BluePeak recently worked with a large MA-PD client that had significant issues with Part D coverage determinations and/or redeterminations needing to be auto forwarded to the independent review entity (IRE) due to missing decision timeframes. The Sponsor had experienced staff turnover in several key positions. Due to the gap in resources and some misunderstandings that led to process issues, the Sponsor was misclassifying appeals, failing to submit appropriate case files to the IRE and lacked the ability to timely effectuate overturned cases.

BluePeak conducted an operational assessment at all applicable levels to determine if changes were required in personnel, processes and/or technology utilized.  These assessments included interviews with current staff, review of platforms, timeliness studies, review of training documents, review of quality review metrics and processes, review of staffing models and staff skills assessments.  Based on these assessments, BluePeak identified that the Sponsor did not have enough staff to conduct the volume of work that needed to occur. Further, the current staff needed additional training and oversight to facilitate a timely, compliant process.

BluePeak immediately deployed five subject matter experts in coverage determinations to support the client’s process.

Outcomes:  BluePeak was able to help the Sponsor identify short-term strategies to bring them into compliance during the implementation of long-term strategy of consolidating all work to one new platform.  These short-term strategies included:

→ Enhancing the staffing model of allocating staff based upon work flow, augmenting staff while the Sponsor hired more staff, and reassigning staff to better align with their expertise;

→ Implementing a more detailed quality review process to include a second level review, which was temporarily staffed by BluePeak personnel during implementation;

→ Implementing an IRE case file checklist and quality review process before the case was sent to the IRE, which was conducted by BluePeak on an interim basis until the Plan could take on the proven process;

→ Implementing post-review of IRE case determinations to allow for the continued quality enhancement of case documentation;

→ Implementing a tracking mechanism for all cases that were forwarded to the IRE to confirm proper receipt and action as required.

These changes reduced the number of cases the Sponsor forwarded to the IRE by more than 75% in 6 months and improved timely effectuation of cases.  BluePeak staff worked with this Sponsor to build repeatable processes, quality review measures, tracking programs and training programs that allowed them to sustain the progress that was made.

BluePeak interim staffing resources allowed this Sponsor to quickly address a significant concern with trusted resources requiring minimal onboarding time.  The Sponsor was able to get this process compliant quickly using the BluePeak interim staffing, while simultaneously working on hiring staff and onboarding thereby addressing the underlying issues immediately.   BluePeak was able to remediate the issues and keep the business running while the Sponsor focusing on adding staff based on the new staffing models.

BluePeak has a proven track record deploying highly trained resources to assist in backlogs and clean-up efforts with plans and PBMs.  BluePeak has successfully deployed nurse, pharmacists and other health care professionals with Medicare experience to assist with Medicare case work.  Whether you need one staff member or several dozen, BluePeak can help.