Why vendor selection matters for health plans
Appeals & Grievances (A&G) now shapes compliance outcomes, Star Ratings, and member loyalty. When making an A&G vendor selection, the vendor you choose determines whether audits feel routine or like fire drills; whether insights are real-time or buried in spreadsheets; and whether members feel heard, or churn. Use these eight factors and the “what to ask” prompts to cut through marketing and find a partner that protects Stars, reduces risk, and earns trust.
Why vendor selection matters for health plans?
A&G sits at the intersection of compliance, member experience, and operations. Complaint volumes are rising, delegated oversight is under scrutiny, and CMS audits tie findings to Stars and CAPs. The right platform drives continuous readiness and insight; the wrong one traps teams in manual work and reactive fixes.
- A&G drives Star Ratings: Over half of Medicare Star ratings tie back to grievance and appeal handling.
- Compliance risk is rising: A single error, such as a late or overturned appeal, can result in a 3-star drop, with cascading consequences for the overall Star Rating and member trust. Source
- Members feel the impact: Poor grievance handling translates directly to lower CAHPS scores and higher attrition.
- CMS audits are more stringent, with findings directly tied to Star Ratings and Corrective Action Plans.
- Complaint volumes are increasing, driven by complex benefits, provider friction, and rising member expectations.
- Delegated entity oversight is under scrutiny, and plans are held accountable for vendor and FDR performance.
In such times, the technology vendor you choose to run your A&G operations isn’t just an IT decision. Your A&G technology vendor will either provide you with continuous audit readiness and actionable insights, or leave you stuck in manual fire drills, resulting in dissatisfied members.
A&G vendor selection checklist: The 8 most important factors in choosing an A&G technology partner
1. Audit readiness by design
Audit prep should never feel like a fire drill. The right system makes CMS universes, scrubbing, and logs a built-in capability, not a scramble. With the right partner, audit prep shrinks from six weeks of effort to six clicks of confidence. And it shouldn’t stop there; a truly audit-ready platform should also generate complete, CMS-compliant IRE packets automatically, ensuring timeliness and accuracy in every escalation.
What to ask: Can you demonstrate how your platform auto-generates CMS universes, validates fields in real-time, maintains continuous audit logs, and produces IRE packets without manual intervention?
2. Structured intake across all channels
Complaints don’t come in one format. If intake isn’t unified, your team wastes time fixing data instead of resolving grievances. A strong vendor normalizes every case at entry, tags it correctly, and links it to member history instantly.
What to ask: Does your system normalize intake across portals, phone, mail, and delegated entities, and auto-classify cases at the source (denial code, benefit type, provider, LOB)?
3. Real-time SLA monitoring
Every missed SLA is a failure in compliance and member trust. Static reports don’t prevent breaches; only real-time dashboards do. A good platform alerts you before deadlines slip, with escalation rules that keep teams accountable.
What to ask: Demostrate how your dashboards surface SLA risks before breaches. Can the system trigger automated alerts or re-routing when a case is at risk?
4. Delegated entity oversight
CMS holds you accountable for DEs just as much as your own staff. Oversight can’t be reactive or spreadsheet-based. The right platform provides DEs with a secure portal, validates their submissions, and compares their performance against plan standards in real-time.
What to ask: How do you enable delegated entities to submit cases securely? Do you auto-scrub their data before intake? Can I monitor DE performance alongside internal operations?
5. Root-cause analytics
Closing grievances isn’t enough. Leaders need to know why complaints occur and how to prevent them. A data-ready platform feeds resolved cases into a trend engine that highlights systemic issues, providers, benefits, or processes.
What to ask: Can your system detect recurring issues across providers, benefit categories, or denial codes? How do you share these insights with teams outside of A&G (e.g., Provider Relations, Network, CX)?
6. Scalability across lines of business
Medicare, Medicaid, and Commercial plans all bring unique compliance requirements. If your vendor can’t scale across lines without custom builds, you’ll hit roadblocks. Modern platforms deliver scalability as a core capability.
What to ask: Can your solution handle Medicare, Medicaid, and Commercial A&G requirements out of the box? How do you onboard new lines of business without costly rebuilds?
7. Seamless integration
An A&G system in a silo creates rework and blind spots. The right platform integrates with claims, UM, provider directories, and CRM systems, providing a single source of truth across all functions.
What to ask: Which enterprise systems do you integrate with today? Do you use open APIs for claims, UM, provider, and CRM? How do you ensure case data flows seamlessly across the enterprise?
8. CMS and healthcare expertise
A vendor without payer and CMS expertise is a liability. You can’t afford to teach your vendor how ODAG universes work or what triggers a CAP. The right partner brings compliance depth, not just software.
What to ask: Tell us about your track record supporting plans through CMS audits. Can you share examples of helping health plans avoid or remediate CAPs? How do you keep up with CMS regulatory changes?
9. Reporting and executive visibility
Reports aren’t just for audits; they’re for running the business. A&G leaders require self-service reporting that can identify SLA trends, recurring grievance patterns, delegated entity performance, and enterprise-wide risk signals. Static reports that require IT intervention are no longer acceptable. The right platform delivers real-time, configurable reports and dashboards that speak to Compliance, Operations, and the C-suite alike.
What to ask: Does your platform offer self-service reporting with drill-downs for SLA, grievance type, and DE performance? Can compliance, operations, and executives each create custom views without IT support? How do reports tie into CAHPS, Star measures, and CMS requirements?
The technology itself is only half the decision. The other half is whether the vendor can prove competence in compliance, scalability, and healthcare operations. Each question above is designed to cut through marketing and get to the truth: Can this partner protect your Star Ratings, reduce compliance risk, and build member trust?
You can download your ready-to-use A&G Technology Vendor Evaluation checklist here:
Download A&G Vendor Evaluation Table
It’s fillable with checkboxes (Yes/Partial/No) and includes a scoring guide, allowing leaders to quickly score each vendor and interpret the results.
What’s at stake in your decision
Choosing the wrong A&G technology vendor doesn’t just mean clunky workflows; it puts your entire plan at risk. It can mean:
- Corrective Action Plans and lost Stars
- Repeated grievances and lower CAHPS scores
- Manual, costly fire drills for every audit
The flip side is just as real. The right partner turns A&G into a strategic asset, where grievances become insights, audits become routine, and member complaints become moments to build loyalty instead of lose it. The right vendor helps you:
- Cut audit prep from 6 weeks to 6 clicks
- Reduce repeat grievances by 50%
- Improve STAR and CAHPS experience measures
- Transform A&G into a driver of member trust
This decision is not about buying software; it’s about whether your plan runs A&G as a reactive cost center or as a driver of trust, compliance resilience, and market differentiation.
Appeals & Grievances is no longer just compliance. It’s one of the strongest predictors of member loyalty, Stars performance, and CMS trust. Your technology vendor choice is strategic, not tactical.
Choose wisely, because in A&G, technology isn’t just infrastructure, it’s the difference between reactive compliance and proactive trust.
Why Inovaare
If you want a partner that delivers CMS-compliant A&G automation, real-time SLA monitoring, delegated oversight, and root-cause intelligence in a single platform, Inovaare’s A&G solution is built for you.
Ready to move forward?
Talk to an expert who understands both CMS compliance and payer operations. Learn how leading health plans are modernizing A&G to stay audit-ready, protect Star Ratings, and deliver measurable member experience improvements.