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Will Your Grievance Resolution Letters Stand Up in an Audit?

By February 18, 2022March 5th, 2022Audits, CMS, Medicare, Part D

Across the Medicare Advantage and Part D industry, Plans are nervous about how their grievance resolution letters will present and stand the test in a CMS Program Audit. BluePeak Advisors is here to help navigate some best practice letter writing tips and how to incorporate a robust grievance resolution letter review process. Plans sometimes wonder if they are including too much information, too little information, or what information to include in the letter that will be appropriate for their members to understand or feel heard. It can also sometimes be difficult to express empathy in grievance resolution letters when the resolution outcome is not what the member wants to hear, or is not in their favor. Below are some best practices and tips on how to write an effective and empathetic grievance resolution letter, and how to implement a pre-closure review of grievance cases and resolution letters.

Grievance Resolution Letter Writing

The biggest challenge for a Plan’s grievance department can be writing a grievance resolution letter. The first step in writing a complete and concise letter to the member is ensuring that the documentation of the case is accurate and complete in the Plan’s system of record. The system should reflect that the member’s complaint(s) or dissatisfaction is clearly documented, each step taken to investigate or resolve the issue(s) is clearly documented, and the outcome, or resolution, to the issue(s) is clearly documented; these are the building foundation for writing a clear, concise grievance resolution letter.

Best Practices – Grievance Letter Writing

  • Create letter templates with canned language geared towards the Plan’s top five grievance types. This also assists with consistency amongst the grievance team.
  • Clearly and accurately state or summarize the member’s dissatisfaction expressed in their phone call or written communication to the Plan.
  • Include empathy statements such as: “We regret any dissatisfaction and inconvenience this matter may have caused you.”, “We want to ensure you receive the best quality of service from our Plan”. Empathy statements add a “hug” to the letter and are effective at making the member feel heard.
  • Use “soft” language and avoid accusatory verbiage. For example, “You shared” as opposed to “You said”.
  • Keep the resolution to each issue short and concise. Each complaint should have a corresponding resolution or outcome explained in a simple manner that is easily understood.
  • Keep industry terms, internal jargon, and acronyms to a minimum. If an acronym is used in the letter, ensure that it is first spelled out. For example: The Centers for Medicare and Medicaid Services (CMS).
  • The documentation of the case in the Plan’s system of record should contain every step or action taken to resolve the member’s complaint(s) however, the resolution letter does not need to include a play by play of every action taken to research and resolve the member’s complaint(s). The resolution letter to the member only needs to contain the outcome or resolution.
  • Make the member “whole” by adding education for the member regarding any relevant benefit information from their Evidence of Coverage (EOC).
  • Try to keep grievance resolution letters to a 2-page maximum.
  • Create a checklist for grievance letter writing

Reviewing Grievance Letters

In addition to any operational or compliance monitoring of closed grievance cases, some Plans have adopted a proactive process to review grievance cases and resolution letters prior to closure. One of the common findings in CMS Program Audits is not addressing all complaints raised by the member. This can be an effective tool to ensure that all complaints have been fully resolved prior to closing the grievance and mailing the letter to the member. Some Plans have delegated a supervisor or more seasoned grievance representative to review 100% of grievance cases and letters for newly hired staff while others choose to perform a 100% review for all staff. Either way, with an effective review process, this can alleviate any internal or external audit findings related to grievances.

Best Practices – Reviewing Grievance Letters

Create a review checklist which includes the following:

  • Ensure letter is appropriately addressed to the member or their authorized representative
  • Ensure the member demographics are accurate
  • Ensure the letter captures the member’s grievance(s) accurately and completely and matches the documentation in the Plan’s system of record.
  • Ensure each complaint/grievance contains a complete and accurate resolution
  • Check for spelling and grammar errors, and ensure letter is written in a clear, concise manner easily understood by the member
  • Ensure the correct Quality Improvement Organization (QIO) information is listed in the any Quality of Care (QOC) grievance letter
  • Ensure any non-QOC related complaints received as part of a QOC allegation also have a resolution contained in the letter
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