Highlights
An Alabama-Based Health Plan Leverages Compliance-Driven Automation to Digitally Transform its A&G Department
3,800
A&G cases
8,512
provider disputes
100%
first-time pass rate
24%
more efficient in case closures than industry average
The Situation
A leading regional health plan in the Southeast, serving Medicare, Medicaid, and Commercial members and offering integrated provider services, was seeking a strategic technology partner to support its Appeals and Grievances (A&G) Department. The goal: implement a purpose-built solution that would improve compliance, reduce administrative burden, and support audit readiness. Top priorities included:
- Improving operational efficiency through automation of A&G case intake, tracking, and resolution
- Streamlining workflows and cross-functional collaboration, reducing delays and manual handoffs
- Ensuring reporting integrity for internal oversight and CMS audit requirements
The plan needed more than software, it needed a trusted partner in appeals and grievances compliance automation.
The Challenge
The health plan faced five critical challenges in its efforts to modernize its Appeals and Grievances (A&G) system and improve compliance automation:
- Cumbersome, manual workflows with too many handoffs and process bottlenecks
- Delays in A&G case resolution, reporting, and universe file generation, impacting audit preparedness
- Inability to generate accurate CMS universes for Part C and Part D reporting, increasing compliance risk
- Limited collaboration across departments, resulting in fragmented data and inconsistent case handling
- Low operational efficiency and inconsistent resolution accuracy, leading to higher rework and audit exposure
These gaps created regulatory risk, operational burden, and a poor member experience—prompting the need for an automated A&G compliance solution.
The Solution
To address the health plan’s challenges, Inovaare deployed its out-of-the-box Appeals & Grievances (A&G) Compliance Automation Solution, a fully integrated, end-to-end system designed to manage the entire A&G lifecycle, from case intake to closure, with built-in CMS compliance logic. As part of the engagement, Inovaare delivered:
- A compliance-driven A&G workflow, fully automated with built-in CMS validation rules
- Role-based access controls for cross-functional collaboration beyond the A&G team
- Integrated universe generation for Part C and Part D reporting, reducing rework and errors
- Real-time synchronization of workflows, reporting, and universe file creation to support audit readiness
- Comprehensive reporting dashboards for full operational visibility and performance monitoring
- A collaborative support model that ensured smooth adoption and long-term scalability
- Extended CMS audit consulting and compliance support to help the plan navigate audits confidently and successfully.
This solution empowered the health plan to standardize processes, eliminate inefficiencies, and proactively manage compliance risks across A&G operations.
The Impact
After going live with Inovaare’s Appeals and Grievances Compliance Automation System, supported by Inovaare’s compliance subject-matter experts, the health plan achieved measurable transformation across audit readiness, operational efficiency, and collaboration.
Key results included:
- Passed the CMS Program Audit submission on the first attempt, a milestone not achieved in over 8 years
- Generated accurate Part C and Part D reports, ensuring timely and fully CMS-compliant universe submissions
- Enabled leaner operations by automating the entire A&G workflow, from case intake to resolution
- Achieved enterprise-wide transparency, with real-time reporting and better alignment across compliance, operations, and IT teams
- Improved workflow accuracy and consistency, thanks to embedded compliance validation and audit logic
Together, the platform and Inovaare’s expert support team helped the health plan shift from reactive compliance to proactive audit readiness.