Why most internal audit tools don’t work as expected for health plans
Every year, CMS program audits trigger millions in penalties and corrective actions for health plans. Conducting a thorough internal audit can help health plans identify potential issues before they result in penalties or other adverse consequences. In 2024 alone, over 60% of audited plans were cited for data integrity issues in their universe files, the single most common cause of audit findings.
Yet, most “internal audit” platforms in the market aren’t built for this reality. They’re generic compliance tools, designed for broad corporate or provider use cases. When applied to payer audits, they leave critical gaps:
- Manual universe generation that consumes hundreds of staff hours
- Disconnected data sources that lead to repeat findings
- Rigid workflows that can’t keep up with CMS rule changes
Platforms like Casenet, HealthAxis, and Symplr have healthcare capabilities, but their audit modules are often extensions of case management systems. While others, such as Sai360, Scrut, MDAudit, and Veradigm, may excel in GRC or provider audit workflows, they lack the deep CMS-specific program audit, focused audit, and data validation audit (DVA) perspective and logic that payers need.
The result? More manual work, higher audit risk, and a constant cycle of fire drills. This is where a healthcare-first audit platform changes the equation.
Inovaare’s healthcare-first platform flips the game.
Here are five core capabilities that position Inovaare as a leader in payer internal audits and ensure every audit is a success:
Built for CMS compliance, not just generic audits
Most general audit tools apply one-size-fits-all frameworks. Inovaare’s internal audit solution is designed around CMS protocols from the start, including universe file requirements, audit timelines, and risk-based sampling logic.
While Casenet and Symplr can configure workflows for healthcare, their audit modules are not pre-built for CMS audit scenarios. This means more customization, higher IT involvement, and slower time to readiness.
With Inovaare, compliance teams work in a platform already aligned to the audit process they must follow, cutting preparation time and reducing the risk of oversight.
Data unification and integrity at the core
Internal audit readiness depends on complete, accurate data. In many health plans, audit-related information is stored in multiple systems, including case management, delegation oversight, member services, and others.
Inovaare connects these data sources into a single audit-ready repository. This eliminates the need for manual reconciliation, ensuring that every audit pull is based on the latest and most accurate information.
Platforms like HealthAxis and Symplr may integrate data, but often require additional connectors or manual exports. For IT and procurement teams, Inovaare’s integrated architecture means fewer vendor contracts, lower maintenance costs, and faster implementation.
Reporting that accelerates decision-making
Audit findings lose value if they take weeks to analyze and interpret. Inovaare’s advanced reporting tool provides compliance and operations leaders with self-service access to live audit metrics, trends, and risk scores, eliminating the need for an IT ticket.
Other platforms offer reporting, but many rely on static exports or scheduled batch runs. In fast-moving audit scenarios, this delay can mean missing a corrective action deadline.
With Inovaare, decision-makers act on near real-time insights, enabling proactive compliance management instead of reactive damage control.
Automation and AI that reduce manual effort
Manual data scrubbing, case classification, and issue tracking slow down audit cycles. Inovaare embeds AI and automation into these steps, from validating universes against CMS rules to generating action items from findings.
Competitors may have automation features, but few are trained specifically for CMS audit data and payer workflows. Inovaare’s healthcare AI(Usher) not only summarizes complex audit data but also creates task-ready to-do lists for compliance teams.
The result: less time chasing errors, more time closing gaps.
Scalability and future-proofing
Regulations change, but your audit platform shouldn’t need a rebuild every time. Inovaare’s low-code/no-code framework enables compliance and operations teams to adjust workflows, add audit types, or update rules without requiring extensive IT projects.
Many general-purpose tools have rigid workflows that require vendor-led changes, often billed separately and delivered at a slow pace.
For procurement and IT leaders, this flexibility means lower total cost of ownership and faster adaptation to new CMS requirements.
What this means for health plans
Choosing the wrong internal audit platform isn’t just a technology risk; it also poses compliance, operational, and reputational risks.
With a CMS-ready, healthcare-first platform, health plans can:
- Avoid penalties and reputational damage from failed audits
- Improve coordination across compliance, operations, and delegated entities
- Reduce IT dependency and vendor sprawl
- Turn audit readiness into an ongoing operational capability, not a once-a-year scramble
According to the OIG, over 70% of Medicare Advantage audit findings in recent years have been linked to inadequate oversight and reporting gaps, issues that Inovaare’s platform directly addresses. By focusing on the realities of payer compliance, not generic audit checklists, it gives compliance leaders a faster, more reliable path to audit readiness and operational resilience.
How Inovaare is positioned for the future of payer audit and compliance
Inovaare offers one connected platform for internal, program, and delegation audits. Its embedded AI, real-time reporting, and unified data architecture enable compliance leaders to maintain continuous readiness, regardless of how CMS rules evolve.
From Medicare and Medicaid to Commercial markets, Inovaare’s track record speaks of a single truth: audit readiness is not an event; it’s an operating model. And the right platform makes that model possible.
Discover how a healthcare-first audit platform can enhance your readiness. Ask for a walkthrough today.
Recommended blogs:
CMS Program Audits: Top 7 Compliance Gaps That Put Health Plans at Risk
How AI Agents Are Transforming Compliance and Operations in Health Plans