Home » Health Care » Case Studies » Case Study #12004

Health Care Case Study

Case #12004: Senior Services Grievance and Appeals

The Senior Services division of a national Health Benefits Organization had recently enrolled over one million new Medicare Part D members. Questas was engaged to assist the Operations and Compliance areas with implementing a Grievance and Appeals (G&A) process that achieved timely resolution of issues, provided status and reporting of all grievances and appeals, and was compliant with CMS requirements.

Our client‘s G&A resources were spread throughout operations and compliance areas, and the processes for tracking, reporting and resolution were not always consistent between areas or associates. Furthermore, although CMS provided specific requirements for tracking, reporting and resolving grievances and appeals, our client wanted to develop more consistent operational tracking and reporting that allowed further causal analysis, prevention where appropriate, identification of areas for further review, and improvement in overall compliance and customer service.

Engagement Highlights

  • Industry:
  • Health Insurance
  • Client:
  • A National For-Profit Health Benefits Organization
  • Assignment:
  • Identify the associates who are responsible for G&A‘s
  • Identify the associates who are responsible for G&A‘s
  • Develop and implement more consistent tracking, reporting and resolution of G&A‘s
  • Develop training curriculum
  • Provide consistent training for associates and monitor results
  • Create and provide managerial and operational reports for the V.P. of Compliance and various state and federal departments
  • Approach:
  • Gained input and feedback from operations and compliance to develop a new process
  • Regularly worked with associates to implement this newly defined process and improve performance
  • Coordinated with V.P. of compliance to gain improved consistency and compliance
  • Quickly centralized all G&A items to reduce inventory and develop process without backlog
  • Provide interim leadership to oversee G&A process
  • Provide daily reporting of all outstanding items and reduce G&A inventory
  • Duration:
  • 10 months


  • CMS compliant G&A process
  • Uniform processes and single accountability established for G&A
  • Newly hired leadership in place
  • G&A staffing model developed
  • G&A Backlog reduced by over 50%
  • Developed ability to conduct further causal analysis to improve overall customer service
  • Training curriculum for ongoing development
  • G&A reporting in place

Related Case Studies