Alabama Health Plan

An Alabama-Based Health Plan Leverages Compliance-Driven Automation to Digitally Transform its A&G Department

A leading regional health plan in the South East that offers Medicare, Medicaid and Commercial plans and provider services was looking for a technology partner who could help their Appeals and Grievance Department to:

• Improve operational efficiency
• Streamline workflows and collaboration
• Achieve reporting integrity

The health plan faced five distinct challenges related to modernizing their Appeals and Grievances system:

• Complex workflows involving numerous manual steps
• Delays across workflow, reporting and universe generation processes
• Inability to generate accurate universes for Part C & D reporting
• Limited cross-functional collaboration
• Lack of efficiency and case resolution accuracy

Inovaare offered an out-of-the-box solution for managing Appeals& Grievances. The A&G system is an end-to-end solution to efficiently manage appeals and grievances from case intake to closure steps. As a part of this engagement, Inovaare:

Implemented its compliance-driven, automated A&G workflow with embedded features

• Implemented its compliance-driven, automated A&G workflow with embedded features
• Flexible role-based user access, including cross-functional teams outside of the A&G
• Fully integrated universe generation for Part C & D reporting
• Real-time, synchronized workflow, reporting and universe generation processes
• Comprehensive reporting for operational transparency
• Collaborative support model
  Extended CMS compliance consulting and support for navigating CMS Program Audits

After going live with the Appeals and Grievances system, combined with Inovaare’s Compliance subject-matter experts, the health plan was able to:

• Achieve a first-time pass rate for CMS Program Audit submission for the first time in over 8 years
• Deliver CMS-compliance Program Audit Part C & D reports through accurate universe generation
• Enable lean operations through end-to-end automated A&G workflows
• Deliver enterprise-wide transparency and cross-functional collaboration through comprehensive reporting in real time
• Improve workflow output accuracy through embedded compliance validation rules

Inovaare offers a Generative AI-powered compliance operating platform, industry-leading solutions and consulting services that enable healthcare payers and providers to transform business operations with improved accuracy and efficiency with a low cost of ownership.