CMS Complaints Management


The Healthcare industry is traditionally built upon the relationships established within the ecosystem of health plans, members and patients. In order to be successful, healthcare payers need to strengthen their relationships with members and patients, and ensure that member complaints are managed as per regulatory mandates. Handling your member’s complaints effectively and efficiently will enable you with the biggest opportunities to retain, and ultimately grow their membership. But many plans continue to struggle to meet CMS’ standards around complaints management due to:

Challenges in meeting CMS regulations around complaints management

What We Offer

VirtusaPolaris’ consumer-centric CMS Complaints Management Solution provides a flexible platform which is cost-effective, easy to maintain and can be rapidly deployed.

  • Auto-case creation and assignment: Automated creation of complaints lists, cases and tasks by direct CMS-integration. Auto assignment of cases based on SLA’s, CMS protocols, skillset and availability
  • Personalized complaint resolution: 360 degree member and provider lookups provides insights into previous complaints, claims, medications, etc.
  • Intelligent work routing: Tracks and organizes activities and notes for real-time inventory views and intelligent routing of work
  • Transparency: Clear visibility into department timelines and SLA-based escalation
  • Stringent quality checks: Appropriate review and audit for resolution per regulatory compliance
  • Continuous quality improvement: Advanced analytics into aggregated portfolio of cases and staff/department productivity trending

How We Deliver Value
VirtusaPolaris offers a personalized approach by leveraging our dedicated specialists with deep technology and healthcare industry knowledge as well as our solution accelerators:

  • Sophisticated UI/UX that improves usability, accessibility, and appearance
  • Opportunity assessments, enabling leaders to drive long-term performance improvement and diagnostic tools, identifying gaps and mapping out future goals.
  • Change management resources including training and QA guides and a maturity model
  • Pre-built software assets, including CMS file processing, guided flows, comprehensive views, portals and reports
  • Process maps and root cause analysis prior to designing ideal end state workflows
  • Transformation playbook with guided implementation methodology

Benefits We Offer
Some of the key benefits of our solution include:

  • INCREASE in member satisfaction and retention due to hassle free complaints resolution
  • INCREASE in CSR productivity due to simpler, unified platform and guided workflows
  • DECREASE in hefty CMS fines and penalties due to timely complaints resolution
  • INCREASE in proactive escalation methods due to availability of historic information