CMS Program Audit Success Story

• 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

The client is a Fortune 500 American health insurance provider dedicated to delivering quality healthcare solutions. With thousands of employees, the health plan serves millions of members across the U.S., offering a wide range of health insurance products and services. It is committed to enhancing health outcomes through innovative solutions and exceptional customer service.

Before implementing Inovaare’s Universe Management System (UMS), the health insurance provider faced several issues with their audit and compliance processes:

• The audit and compliance department relied on manual systems and processes, taking over two weeks to combine data from over 27 different contributors.
• Utilized conventional tools like MS Office and SharePoint to manage and create audit-related files, leading to a stressful and error-prone process.
• Generating clean universes was difficult, often resulting in unsatisfactory outcomes and poor audit performance.
• The manual and inefficient processes led to increased external audit costs and time-consuming follow-ups.

The health insurance provider decided to adopt Inovaare’s Universe Management System (UMS) to enhance their audit and compliance processes. Their specific goals included:

• Automate the collection, review, correction, and aggregation of audit universes to reduce manual effort, errors, and external audit costs.
• Ensure data consistency, reduce subjectivity in audit reviews, and enhance audit preparedness with better data management and Timeliness Dashboards.
• Consolidate data from multiple sources for efficient and accurate universe generation, compliance monitoring, and improved reporting for increased visibility and control.

After evaluating several technology solutions, the health insurance provider selected Inovaare’s Universe Management System (UMS) due to its robust automation capabilities, built-in compliance rules, and comprehensive data management features. The key aspects of the solution deployment include:

• The UMS automated the collection, review, correction, and aggregation of audit universes. Its Universe Scrubber scans up to 100,000 records per minute, significantly reducing manual review effort and errors.
• UMS includes built-in CMS compliance rules and allows for quick configuration of customer-specific rules reducing the risk of non-compliance.
• Timeliness dashboards provide real-time visibility into data outliers, enhancing preparedness and compliance monitoring.
• The UMS consolidates data from multiple sources, ensuring efficient and accurate universe files for consistent compliance monitoring and audit reporting. This enables data-driven decisions and better audit outcomes.

The implementation of Inovaare’s Universe Management System (UMS) has provided the health insurance provider with unprecedented levels of efficiency and accuracy in their audit processes, leading to numerous benefits:

• Automated processes and high-speed scrubbing capabilities have significantly reduced manual effort and errors, ensuring audits are prepared quickly and accurately.
• Timeliness Dashboards offer real-time visibility into data outliers, enhancing compliance monitoring and enabling proactive management of compliance risks.
• The automation and centralization of data management have reduced the cost of audit follow-ups by 67% and audit review time by 90%.
• Eliminating manual data entry and integrating built-in compliance rules have resulted in more accurate and consistent data, reducing subjectivity and increasing the reliability of audit outcomes.

The implementation of Inovaare’s Universe Management System (UMS) has led to significant and measurable improvements for the health insurance provider.

• The audit review time was reduced by nearly 90%, allowing the team to focus on strategic tasks due to automated processes drastically cutting down preparation and review times.
• The cost of audit follow-ups decreased by 67% due to streamlined processes and enhanced accuracy, leading to substantial savings.
• Subjectivity in data validation decreased by 88%, and consistency increased as built-in compliance rules minimized human errors, ensuring reliable and compliant audits.
• Time spent on data validation alone was reduced by 58%, with high-speed scrubbing capabilities.
• The health insurance provider achieved a 100% success rate in passing CMS audits on the first submission, as all audit universes were clean and compliant.