Highlights
California Health Plan Appeals & Grievances Department Achieves No Findings in Medicare and Medicaid Audits Using Inovaare A&G Platform
3,800
in annual operational savings
0
CMS A&G audit findings
0
DHCS A&G audit findings
110
A&G Leadership/IT monthly hours saved
0
regulatory fines
About the Health Plan
A California-based health plan with with over 100,000 members has been serving its community for over 20 years and was looking for a CMS and CA DHCS/DMHC compliance technology partnerwho could help them:
- Incorporate all regulations into a workflows and rules engine
- Centralize business processes for managing all member-related
- appeals and grievances cases
- Track all the member appeals and grievances
- Create regulatory compliance and analytics reports
- Integrate evolving federal and state regulations into its system
Lastly, the health plan faced challenges maintaining everchanging federal and state regulations — a very time consuming process that reduced productivity and compliance.
“Inovaare’s Appeals and Grievances Platform is a decade ahead of their competitors. Their expertise in compliance is unparalleled and we felt they actually knew more about compliance than we did, which means we have a trusted compliance partner, not just a tech vendor”
Director of Appeals and Grievances
The Requirements
The health plan needed a compliance-driven appeals and grievances technology platform. They also needed a way to accurately deliver regulatory reports and universes. So they searched for an A&G system which would drive efficiency and support consistent compliance.
The specific platform requirements included:
- An executive dashboard
- Out-of-box regulatory reports and universes
- Workflows which maintained compliance
- The ability to capture all case types as well as multiple cases from the same member
- Functionality to collaborate with other departments to resolve cases
- Easy-to-use tasks for the Medical Directors
The Problem
The company faced four distinct challenges related to managing appeals and grievances. First, a decentralized appeals and grievance business process caused inconsistencies and resolution delays that led to member frustration and regulatory non-compliance.
The second challenge was a poor tracking system resulting in consistent difficulty capturing relevant information and outreach attempts needed to resolve a case.
The health plan was also not able to accurately produce the regulatory or management reports necessary to stay compliant and operationally efficient. This led to fines issued by regulators.
The Solution
The health plan wanted to go live quickly, given the challenges with their current state, and they chose Inovaare as their Appeals & Grievances solution provider. They signed the contract with Inovaare for their MMP and Medicaid lines of business at the beginning of a quarter and, by the end of the quarter, not only did they go live, but they pulled in all the legacy data from the existing system so that all future reporting could be conducted in Inovaare’s appeals and grievances platform.
“The solution offered Inovaare’s Executive Dashboard — which includes all the management KPI reports, regulatory reports and CMS universes and Inovaare’s compliancedriven workflows”
Inovaare’s A&G system was the guiding light for our team, in terms of staying compliant will all federal and state regulations. Furthermore, cases which used to take us right up until the regulatory due date to complete, or after — due to the inefficiencies with the manual processes — are now closed well ahead of the regulatory due dates”
Director of Appeals and Grievances
The Results
After going live with Inovaare’s A&G solution, the health plan soon benefitted from compliance adherence, operational efficiency and increased capacity of critical resources. Here are some of the highlights:
- Executive Dashboard: the centralized source for reporting added value immediately for management Ability to document and track A&G activities: the added functionality decreased resolution time by over 30%
- Unprecedented audit results: the health plan underwent both a CMS Program Audit and a state Medicaid audit and achieved zero A&G-related findings – a testament to the compliance-driven workflow automation tools available within the Inovaare system
- Reduced operational auditors: the streamlined auditing workflow increased operating leverage with net result in annual operational savings of $160,000
- Automated processes: the system reporting reduces hours required to ensure case priority guidelines, resulting in recovered hours that can now be applied to more strategic initiatives
- Ease of analyzing universes and regulatory reporting: the manual process took days, but now the health plan benefit from the one-click regulatory report function Exceptional return on investment: the A&G leadership and IT teams recovered 110 hours per month, or 1,320 hours per year, which—when converted to dollars—was estimated at $135,000 annually