AI Agents for Payer Compliance and Operations Automation
Payer teams don’t need another chatbot, they need intelligent agents that can take real action. Inovaare’s AI agents are embedded with federal and state regulatory requirements, enabling seamless automation of payer operations.
Turn compliance pressure into operational intelligence
Regulatory notice management agent
Stay ahead of CMS updates with instant policy and workflow impact mapping.
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Regulatory audit automation agent
Generate and validate CMS universes in minutes, not weeks.
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Member appeal and grievances intake automation agent
Transform unstructured appeal submissions into audit-ready cases.
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Provider dispute intake automation agent
Streamline provider disputes with smart intake, routing, and tracking.
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Built-in intelligence. Configured for compliance.
Healthcare-specific logic
Agents are trained on Medicare, Medicaid, and Commercial workflows, no generic AI models.
Built-in compliance rules
CMS audit protocols, HPMS triggers, and regulatory timelines are pre-mapped into decision flows.
Human-in-the-loop design
Thresholds, escalation logic, and approval workflows ensure oversight stays with your team.
High traceability
Every agent action is logged, timestamped, and reportable for full traceability.
Real-time data parsing
Structured and unstructured inputs are parsed instantly, no manual triage needed.
Modular deployment
Use standalone or embed into A&G, Audit, UMS, or Reporting modules as an add-on.
HIPAA-compliant
Runs on our HIPAA compliant health cloud with strict access controls and role-based visibility.
NLP tuned for healthcare
Turns letters, findings, and memos into structured, actionable data based on contextual understanding.
Intelligence that amplifies payer workflows
A&G management
Effortlessly manage appeals and grievances! Automate workflows, reduce manual effort, and ensure timely resolutions. Improve compliance and operational efficiency while enhancing member satisfaction with seamless, accurate, and real-time tracking of appeals and grievances. ×
Member journey dashboard
Gain Comprehensive Insights into Member Journeys! Track every touchpoint and interaction across the member lifecycle, providing a holistic view that drives better decision-making. Identify trends, improve service delivery, and increase member satisfaction with detailed, actionable insights. ×
PQI & QIO
Ensure the highest standards of quality care with our Potential Quality Issue (PQI) & Quality Information Organization (QIO) solutions. Automate quality improvement processes, monitor performance metrics, and comply with regulatory standards. Drive continuous improvement in care delivery and outcomes, and maintain excellence in healthcare services. ×
Data scrubber suite
Our Data Scrubber Suite helps you maintain clean, accurate data for all your reporting needs. Automate data scrubbing processes to identify and correct errors, ensuring compliance with regulatory requirements. Improve data integrity, reduce risks, and enhance decision-making with reliable data. ×
Regulatory notice management agent
- Read, tag, and summarize HPMS memos; flag impacted policies and procedures, and auto-create action items and assign follow-ups with deadlines.
- Track regulatory changes across federal, state, and plan-specific guidelines.
- Generate compliance impact reports for leadership and operations teams.
Regulatory audit automation agent
- Reads incoming audit notices and automatically initiates the required workflows.
- Runs pre-submission checks to flag data inconsistencies before CMS finds them.
- Maintains a defensible audit trail linking incidents, CAPs, and evidence.
Member appeal and grievances intake automation agent
- Ingests appeals across all submission channels; phone, fax, portal, mail.
- Extracts denial codes, benefit types, provider and member data.
- Converts unstructured attachments into searchable, auditable case records.
Provider dispute intake automation agent
- Captures disputes from portals, delegated entities, or mail/fax and brings them into a single intake hub.
- Auto-classifies dispute type, provider, contract terms, and escalations.
- Routes disputes to the right resolution queue instantly.
AI that adapts to you, not the other way around.
Configurable rules
Tailor intake, classification, and workflows without IT bottlenecks.
Extendable design
Add new data sources, reporting formats, or compliance logic.
Custom agents
Build new AI Agents from scratch using low-code/no-code tools.
Embedded copilots
Leverage Usher’s conversational interface to query, validate, and even design new workflows.
Future-proof design
Build once, adapt endlessly, keeping compliance and operations current without costly re-engineering.
Healthcare-native AI. Built for payers.
Intelligent compliance
AI Agents ensure every intake, action, and outcome follows built-in rules, policy triggers, and CMS protocols.
Lower cost to operate
Agents reduce manual work, speed up turnaround, and free teams to focus on outcomes.
Full visibility, zero IT delay
Dashboards and reports are owned by business users with real-time data flow and control.
Member-first by design
Agents spot risks early, automate next steps, and help prevent repeat complaints.
Inovaare Recognized in Gartner® Hype Cycle™ for Healthcare Payers
We’ve been recognized as a Sample Vendor in Gartner® “Hype Cycle for U.S. Healthcare Payers, 2024” report, for innovative solutions in the categories of LLMs for Healthcare Payers and Consumer-Centric Health Products.
Gartner® in it’s report “AI Reshapes How U.S. Healthcare Payer CIOs Do Business,” predicts that by 2027, GenAI solutions will reduce administrative cost by 30% for most health insurers with over a million members.
Regulatory Compliance
Yes. All AI Agents run on Inovaare’s HITRUST-certified, HIPAA-compliant Health Cloud Platform. CMS compliance logic is built in, and every agent maintains a full audit trail with timestamps and evidence, ensuring defensible oversight during CMS Program Audits.
Agents continuously monitor SLAs, auto-scrub universes, and validate files against CMS rules. This reduces late responses, repeat errors, and corrective action plan (CAP) exposure—helping plans achieve zero findings during audits.
Pricing & Implementation
No. AI Agents can be deployed standalone or as part of the Health Cloud Platform. Many clients start with a single high-impact agent and scale over time.
Yes. Our pricing includes implementation, onboarding, and ongoing support.
Most implementations are completed within weeks, not months. Our prebuilt templates and rapid deployment framework minimize disruption and deliver faster time-to-value.
Pricing is flexible and based on deployment scope. Options include per agent module, enterprise bundles, and platform-wide licensing. Volume-based discounts and phased adoption models are available.
Technology
Yes. Agents connect via secure APIs to platforms like Facets, QNXT, HealthRules, and custom payer systems. They can also ingest data from delegated entities (FDRs) to ensure complete oversight.
Yes. The platform is low-code/no-code, allowing compliance and operations teams to configure workflows, rules, and dashboards without IT bottlenecks.
Operations
Agents automate intake, classification, scrubbing, and reporting. This reduces manual workload by over 40%, ensures timely case handling, and provides real-time dashboards for executives.
No. The platform is built to empower business users through no-code configuration. IT involvement is minimal beyond initial setup, freeing up technical resources for strategic priorities.
Yes. Through the Usher platform, AI Agents are modular and extendable. Plans can build Custom Agents with tailored workflows, data sources, or compliance logic.