Highlights
Streamlining CMS Program Audits
- Automated the collection, review, and submission of audit universes through Inovaare’s Universe Management System (UMS)
- Centralized data management for efficient and accurate universe generation
- Improved compliance monitoring and audit readiness with Timeliness Dashboards
- Significant reductions in audit review time and external audit costs
Quantifiable Results
80%
reduction in data submission effort for CMS Program Audits.
85%
reduction in costs associated with external auditors.
60%
reduction in time required for mock audits.
75%
reduction in effort to secure clean universes from FDRs.
The Customer
The client is a Fortune 500 health plan that serves Medicare and Medicare-Medicaid (MMP) members nationwide. The health plan is dedicated to delivering quality healthcare services while maintaining compliance with stringent CMS requirements.
Challenges
The health plan struggled with outdated, manual workflows that made audit preparation time-consuming, error-prone, and costly. These inefficiencies not only impacted internal productivity but also put the organization at risk of non-compliance with CMS reporting standards.
Key challenges included:
- Manual processes: Compliance and audit teams relied heavily on spreadsheets and manual coordination, resulting in inefficiencies, delays, and data entry errors.
- Resource drain: Preparing CMS universe submissions consumed excessive time and internal resources, driving up operational costs and stretching compliance bandwidth.
- Inaccurate reporting: The absence of automation led to inconsistent, redundant data handling and unreliable reporting outputs, jeopardizing audit performance and increasing rework.
Goals
To modernize its audit and compliance operations, the health insurance provider implemented Inovaare’s Universe Management System (UMS). The platform was selected to address inefficiencies and strengthen CMS audit readiness across the enterprise. Key goals included:
- Automate compliance processes: Streamline CMS Program Audit preparation by automating universe file generation, scrubbing, and submission workflows
- Enhance reporting accuracy: Ensure timely, error-free universe submissions that align with CMS formatting and validation rules
- Reduce audit and compliance costs: Minimize manual effort, follow-up cycles, and rework through high-speed scrubbing and centralized data management.
Solution
After evaluating several vendors, the health plan chose Inovaare’s Universe Management Suite for its ability to deliver fast, accurate, and audit-ready CMS universe files—backed by automation, real-time insights, and built-in compliance intelligence.
Key capabilities that influenced the decision included:
- Automated universe scrubbing and validation and correction, significantly reducing manual errors and preparation time
- Continuous monitoring and early issue detection, enabling proactive compliance risk management
- Built-in CMS compliance rules, with the flexibility to configure plan-specific validations, ensuring alignment with regulatory standards
- Real-time visibility with Timeliness Dashboards, allowing teams to quickly identify data outliers and stay audit-ready year-round
- Centralized data consolidation, integrating inputs from multiple systems to generate accurate, compliant, and complete universe files for CMS audits and internal reporting
The Universe Management Suite gave the health plan a scalable, future-ready foundation for improving audit outcomes and making faster, data-driven compliance decisions.
“When we started scrubbing, we had 10,000–15,000 error counts. We significantly cut down the error count and drastically improved our ability to submit CMS-compliant universes quickly. Inovaare’s Universe Management solution has exceeded our expectations in every way. We are particularly impressed with the accuracy and reliability of the findings on universe errors.”
Associate Vice President, Nationwide California-based Health Plan
Benefits
The implementation of Inovaare’s Universe Management System (UMS) delivered a step-change in audit efficiency and compliance accuracy for the health insurance provider. By automating key audit workflows and enhancing data integrity, the plan transformed its audit posture from reactive to proactive.
Key benefits included:
- Significant reduction in manual effort, enabling faster, more accurate CMS audit preparation and submission.
- Real-time monitoring and intelligent error detection, ensuring continuous alignment with CMS compliance requirements.
- Lower audit-related costs and resource burden, with substantial reductions in both external audit expenses and internal staff hours spent on universe preparation.
UMS enabled the provider to operate with greater confidence, speed, and control across the entire audit lifecycle.
Outcomes
UMS delivered measurable, high-impact results across compliance, cost, and operational efficiency:
- Audit review time reduced by 90%, enabling teams to shift focus from manual prep to strategic initiatives.
- External audit costs decreased by 67%, driving substantial operational savings.
- 100% CMS audit success rate on first submission, with clean, compliant universes and no rework required.
These outcomes reflect a shift toward a scalable, automated compliance model, built for speed, accuracy, and continuous audit readiness.