Appeals & Grievances

California Health Plan Achieves Zero A&G Audit Findings and $160K in Operational Savings with Inovaare

California Health Plan Appeals & Grievances Department Achieves Zero Findings in Medicare and Medicaid Audits Using Inovaare’s A&G Platform

A California-based health plan serving over 100,000 members for more than 20 years needed a technology partner to help meet its growing compliance and operational demands tied to CMS and CA DHCS/DMHC regulations.

The plan’s goals:

• Embed federal and state regulations into a workflows and rules engine
• Centralize all business processes related to member appeals and grievances
• Track and manage every A&G case, including multiple cases from the same member
• Generate accurate regulatory and analytics reports
• Adapt quickly to evolving CMS, DHCS, and DMHC regulations

To address these challenges, the health plan sought a compliance-driven A&G platform that could:

• Provide an executive dashboard for visibility and decision-making
• Offer out-of-the-box CMS and DHCS/DMHC universes and reports
• Deliver pre-built workflows aligned with regulatory rules
• Support collaboration across departments
• Enable easy task management for Medical Directors and other key roles
• Scale with ongoing regulatory and operational changes

The health plan faced four pressing challenges in managing appeals and grievances:

• Decentralized operations caused delays, inconsistent resolutions, and member dissatisfaction.
• Inadequate tracking tools made it difficult to capture documentation and outreach history needed for resolution.
• Manual reporting led to frequent errors, incomplete submissions, and regulatory fines.
• Constant regulatory changes required excessive manual intervention, draining productivity and increasing compliance risk.

The health plan selected Inovaare’s Appeals & Grievances Solution to replace its outdated, manual system. Speed was critical—and Inovaare delivered.

• Contract signed at the start of the quarter
• Go-live achieved within the same quarter
• Legacy data fully migrated, ensuring continuity and compliance reporting from day one

“The solution offered Inovaare’s Executive Dashboard — which includes all the management KPI reports, regulatory reports and CMS universes and Inovaare’s compliancedriven workflows”

After implementing Inovaare’s Appeals & Grievances (A&G) solution, the health plan quickly realized measurable gains in compliance, operational efficiency, and resource optimization.

Key outcomes included:

• Executive dashboard for real-time oversight: A centralized reporting source provided immediate value to leadership, improving visibility into case trends and resolution timelines.
• Faster case resolution through automation: The ability to document, track, and manage A&G activities within the platform reduced resolution time by more than 30%.
• Flawless audit performance: The health plan passed both a CMS Program Audit and a state Medicaid audit with zero A&G-related findings—a direct result of Inovaare’s compliance-driven workflows and automation tools.
• Lower audit overhead, higher savings: A streamlined audit process enabled a reduction in operational auditors, resulting in $160,000 in annual savings.
• Improved resource utilization: Automated case prioritization and reporting functions saved hours each week, allowing staff to focus on strategic tasks rather than manual tracking.
• One-click regulatory reporting: What once took days is now completed in minutes, thanks to easy universe analysis and auto-generated regulatory reports.
• High return on investment: A&G and IT teams collectively recovered 110 hours per month (1,320 annually), equating to $135,000 in cost savings.