Appeals and Grievances Software | CMS Appeals and Grievances

Why the Largest Health Plans Trust Inovaare A&G Solutions

The real-time data platform continuously delivers consistent results

Effective oversight and management of Appeals & Grievances (A&G) can be challenging. Whether a Medicare, Medicaid, Marketplace or commercial healthcare provider, health plans must ensure their compliance procedures—as well as those of their delegated entities—are updated and ready for audit.

Inovaare’s industry-leading Appeals and Grievances software empowers compliance teams with end-to-end visibility of real-time data for accurate monitoring, better decision making and expedited resolutions. The platform also allows for Appeals and Grievances software configuration to meet rapidly evolving business and regulatory requirements.

Achieve no audit findings to Improve star ratings

Member Appeals & Grievances

Designed by industry leaders who oversaw Appeals & Grievances departments within large health plans, Inovaare’s comprehensive Appeals and Grievances software suite empowers operations teams with real-time data visibility to support accurate monitoring, better decision-making and expedited resolutions. The cloud-based data platform enables health plans to meet constantly evolving business and regulatory requirements while providing a seamless experience that simplifies workflows and creates better member experiences, which results in improved star ratings.

Implement Dynamic case management workflows

Provider Dispute Resolution

CMS expects all Medicare Advantage Organizations (MAOs) and payers to resolve payment disputes with non-contract providers promptly and ensure payments are made in accordance with the law. CMS account managers have been instructed to closely monitor MAOs’ actions, in this regard, and will take compliance actions as necessary. Inovaare's cloud-based Provider Dispute Resolution (PDR) software allows health plans to track, trend and process provider disputes, which helps to eliminate any compliance actions taken by CMS. Efficiently manage the PDR process through innovative automation.

Mitigate Compliance Risk

Sales Allegations

Sales Allegations are hard to prevent and, in many cases, just as difficult to track, due to the many aspects required to ensure CMS compliance in health-plan investigations. The fact that CMS is relatively silent on the specific requirements around investigation and closure of sales allegations makes it even more difficult and confusing. While health plans can’t prevent these instances, Inovaare’s Sales Allegations module helps health plans to ensure complaints are investigated and closed properly, reducing non-compliance risk.

Ensure 360-degree view of Decision processes

QIO Appeals

QIO Appeals track and trend the issues being reviewed by the QIO department. The workflow starts with the Intake Step, which includes member and issue documentation. Next is the Review step—which includes the details of issue or treatment—and the final step is Case Closing, which includes the determination and effectuation. The system allows for decisions made by the QIO to be tracked at each step—from intake through closure—guaranteeing each decision rendered is executed efficiently.

Manage and Track Member Incidents

Complaint Tracking Module

Mismanaged complaint tracking compounds member issues and, over time, it results in major operational and reputational damage. Inovaare's experts designed its Complaint Tracking Module (CTM) so that several cases for a member can be created at once using linking technology. The common information is passed to each case—which eliminates double or triple entry—so only the unique information for each case will need to be completed (i.e., categorized). It even enables compliance teams to download cases from the CMS Health Plan Management System (HPMS) and systematically upload required HPMS files, saving health plans significant time and effort.

Perfect Regulatory Audits
- Inovaare customers have achieved no audit findings with our Appeals & Grievance solution
Improved Star Ratings
- Inovaare customers have improved revenues though enhanced member experiences and star ratings which resulted in plans achieving a 5-star Rating
Improved Operational Efficiency and Cost Savings
- Inovaare customers gained a 41% cost reduction through automated processes
No Penalties and Non-Compliance Notices
- Inovaare customers have eliminated Civil Monetary Penalties (CMPs) and Notices of Non-compliance (NONCs); as regulatory requirements change, Inovaare’s solution changes so health plans will always be compliant
Simplified Regulatory Reporting
- Inovaare customers have enjoyed one-click regulatory reports and CMS universes

Configurable appeals and grievances processes for Medicare, Medicaid, Commercial, ACO, MMP, MSO and PACE lines of business
Real-time activity monitoring
Unique appeals and grievances tracking
Complex business rules supported
Adjustable rules to keep pace with changing business requirements
Regulatory requirements designed into the core
Effective adherence to compliance deadlines
Flexible workflow rules with multiple configuration options

Appeals & Grievances Software Packages

A&G Pro 30 and A&G Enterprise

Inovaare knows the world of Medicare, Medicaid and Commercial health plans from decades of hands-on A&G department oversight. This expertise resulted in an Appeals and Grievances software platform rich in features and it’s unparalleled in the market.

Inovaare created two Appeals and Grievances software packages to meet any health plan’s unique requirements: A&G Pro 30 and A&G Enterprise. For many health plans, A&G Pro 30 is an out-of-the-box solution that can be implemented within 30 days to lower operating costs and improve member experience. However, for payers who require more complex processes, A&G Enterprise can be customized to address each requirement.

Here are just some of the benefits that will simplify your operations:

Personalized Home Pages by Role

Configure the landing page and view to optimize productivity
Auto-prioritize cases and tasks to ensure the right issues are being worked first by agents
Receive the most urgent case alerts to help ensure compliance

Dynamic Case Management

Connect people
Create a 360-degree view of the member
Control end-to-end visibility for efficient issue resolution

Built-in Compliance

Eliminate non-compliance
Ensure cases are closed properly
Automate outreach emails or written notifications as required

Logical Workflows

Preconfigured workflows embedded right out of the box to drive compliance
Secure leader approval with 14-day extensions
Capture AOR or WOL documents from invalid requestors

Auto-populated Letters

Set conditions for letters and only make them available when appropriate
Automate approval and publishing processes
Ensure letters are compliant before they are sent to recipients

Dashboard and Analytics

View work activities, urgent issues, high/low performers and compliance-related reports
Configure customized KPIs within a configurable platform
Analyze intuitive dashboards

Appeals & Grievances