Helping CMS modernize its Eligibility Appeals program
Key takeaways
To simplify its healthcare coverage eligibility appeals process, the Centers for Medicare & Medicaid Services (CMS) tapped Maximus to modernize its Eligibility Appeals Operations Support (EAOS) program. Maximus leveraged emerging technologies, advanced analytics, application development, and IT modernization to develop a first-of-its kind environment for EAOS built entirely in the CMS cloud with a focus on human-centered design and accessibility compliance.
Streamlining complex processes and innovating IT infrastructure.
Situation
CMS provides health coverage to more than 100M people through Medicare, Medicaid, the Children’s Health Insurance Program, and Health Insurance Marketplace. The healthcare coverage appeals process can be daunting for consumers, and CMS’s objective is to help them navigate the process with ease to ensure a positive customer experience.
Challenge
CMS faced needed to improve the coverage eligibility determinations process, including reducing a case backlog that often delayed adjudication and finalization of appeal decisions. Proven technology solutions and services were required to help simplify the process.
Solution
CMS tapped trusted partner Maximus to leverage extensive experience in accelerating digital transformation and modernizing IT systems. With a holistic focus on innovating the CMS IT infrastructure, our team provided an integrated suite of operations, policy, IT, and support services including:
- A simplified online appeal submission process, adding a user-friendly option to traditional mail and fax receipt methods
- Streamlined adjudication processes, enabling case resolution prior to the hearing phase
- Real-time hearing selection and confirmation with the CMS Hearings Call Center
- A convenient eRFI process, enabling appellants to submit supporting appeals documentation digitally
Leveraging industry-leading technologies to streamline appeals.
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How We Did It
Maximus team ensured success with services that met all technical, utilization, and security standards for CMS. Our team:
- Developed a first-of-its-kind program environment built entirely in the CMS cloud
- Utilized existing CMS tools to enable rapid modernization and development efficiencies
- Leveraged the Scaled Agile Framework (SAFe) methodology for business agility
- Focused on human-centered design to improve CX for the appeals process
- Adhered to 508 compliance requirements to ensure full accessibility to all users
Results
- Enhanced intake, adjudication, hearing support, effectuation, call center, mailroom, and correspondence operations
- Improved quality control, training, and finance tasks critical for effective appeals case management
- Increased online submission rate to 80%, thereby improving processing speed
- Reduced hearing case volume by 71%
- Decreased time to issue hearing decisions to within one business day
- Reduced call wrap time by 50% for more efficient customer service
Our strategic collaboration with CMS supported all functions of the appeals process associated with the Affordable Care Act, including both operations and digital tasks.