The Hidden Cost of Manual Appeals & Grievances (A&G) for Health Plans

Appeals & grievances (A&G) are among the most complex and compliance-sensitive processes for health plans. Every appeal requires document collection, case routing, clinical review, member communications, compliance tracking, and audit-ready record keeping. 

When these activities rely on manual processes and disconnected systems, costs rise, resolution tiles slow, and regulatory risk increases.  

According to our partner, Cognizant, manual A&G handling can cost up to $45 per case due to document gathering, multiple handoffs, medical review, and compliance tracking. Appeals may arrive through mail, fax, portals, call centers, and regulators—often incomplete, misclassified, or duplicated, delaying the compliance clock. 

 In the US, the American Hospital Association ( AHA) found that Medicare Advantage denials rose 55.7% year over year, driving higher appeal volumes and regulatory scrutiny. Health plans must also meet strict response deadlines – sometimes as short as 24 hours – while maintaining complete audit trails across intake, communications, decisions and document retention. 

Bottom line: The process is expensive to operate, difficult to scale, and increasingly risk to manage manually.  

Smart Communications Creates Value Across the A&G Lifecycle 

Smart Communications’ platform aligns naturally to A&G needs because it covers the entire process: intake → orchestration → communications → archiving. Payers typically integrate the Smart solutions with a case management system (e.g., Pega, Salesforce, etc.). 

SmartIQ™ for Intelligent A&G Intake 

What it solves 

ROI impact 

SmartPATH™ for Case Orchestration & Digital Delivery 

What it solves 

Value drivers 

ROI impact 

SmartCOMM™ for Compliant A&G Communications 

What it solves 

Value drivers 

ROI impact 

SmartHUB™ for A&G Archiving & Audit Readiness 

What it solves 

Value drivers 

ROI impact 

How to Calculate the ROI of Modernizing Appeals and Grievances Processes 

We can calculate the return on investment of investing in a Smart appeals and grievances solution. We’ll need some input from you to personalize the calculations, but we’ll start with an example that you can customize. Here’s what you’ll need: 

The following calculations show how these inputs can translate into potential savings across operational costs, labor productivity, compliance, call volume, and audit and legal costs.  

Output Metrics of the A&G ROI Calculator 

After considering your inputs and running through the calculations, above, we will be able to determine: 

Why A&G Is an Ideal ROI Use Case for Smart Communications 

Unlike claims where savings are incremental, A&G ROI compounds across: 

Appeals & Grievances are no longer a back office necessity; they are a financial, regulatory, and member experience lever. SmartIQ, SmartCOMM, SmartPATH, and SmartHUB together enable payers to lower cost, reduce risk, and deliver defensible, compliant outcomes at scale. 

With documented A&G automation savings of 30–40% per case and rising volumes, even mid-size plans can justify investment quickly. 

What Could Your Organization Save? 

See how much your health plan could save by automating appeals and grievances. Calculate your potential ROI today.  

Frequently Asked Questions 

Q: Why should health plans modernize appeals and grievances?

Health plans should modernize appeals and grievances to reduce manual work, improve turnaround times, strengthen compliance, and deliver a better member experience. Automation can also reduce costs by streamlining workflows and reducing avoidable errors. 

Q: What should health plans look for in a modern appeals and grievances solution? 

Look for a solution that automates workflows, supports regulatory compliance, integrates with existing systems, and provides visibility through tracking and reporting. It should also enable personalized, omnichannel communications throughout the appeals and grievances process. 

Q: How can Smart Communications help me improve my appeals and grievances workflow? 

Smart Communications helps health plans automate and streamline appeals and grievances workflows, from intake and routing through decisioning and member communications. Its solutions can reduce manual effort, improve consistency and compliance, and create a more connected member experience.