Managed Care Industry Experience

Strategic Management has been providing compliance-related services to health insurance plans and managed care organizations (MCOs) for more than 20 years.  MCOs, such as HMOs, health plans, and first tier, downstream, and related entities (FDRs), including third-party payers, maintain mandatory compliance programs, must comply with countless regulatory requirements, and are subject to audits and increased regulatory and public scrutiny. The Centers for Medicare & Medicaid Services (CMS) in particular requires vigilance in MCOs’ compliance posture.

Strategic Management and its knowledgeable and experienced consultants can help health insurance organizations / MCOs with their compliance needs.  Our experience includes working with publicly traded MCOs with products throughout the United States, Blue Cross Blue Shield organizations, accountable care organizations (ACOs), regional managed care organizations, including not-for-profits, and FDRs.  We provide the services outlined below and more.  For additional information regarding our advisory services related to managed care, please contact us at (703) 683-9600 or [email protected].

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Compliance Program Services

Compliance Office Services:

Compliance Program Reviews and Implementation for Parts C & D:

  • Provide compliance program development and implementation services.
  • Provider compliance program resource and organizational planning.
  • Review organizational structure of the Medicare compliance program.
  • Evaluate and assess effectiveness of MCOs’ compliance programs.
  • Review written policies and procedures related to the design and operation of the Medicare compliance program including the standards of conduct/code of conduct.
  • Review hotline and other lines of communication.
  • Review enforcement of standards of conduct and policies.
  • Review auditing and monitoring protocols, work plans and reports.
  • Review auditing and monitoring protocols and efforts conducted in relation to FDRs.
  • Identify strengths/accomplishments of the compliance program.
  • Provide strategies/recommendations for compliance program improvements.
  • Conduct quality assurance (QA) reviews.
  • Perform risk assessment and risk management services.
  • Design monitoring programs and procedures.
  • Survey staff on knowledge of compliance program.

First Tier, Downstream, and Related Entities (FDRs) Oversight Services:

  • Evaluate effectiveness of MCO FDR oversight program.
  • Design and implement FDR oversight programs.
  • Conduct vendor audits.
  • Prepare or review written standards of conduct, policies and procedures.
  • Develop, revise, and administer fraud, waste, and abuse compliance training to FDRs.
  • Conduct Part D Compliance Program Pre-Implementation Audits to effectively oversee and manage FDRs.

Audits and Risk Assessments

Independent Auditor Validation Services:

The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage and Part D organizations (Sponsors) to hire Independent Auditors (IAs) to validate corrections of sanctioned and non-sanctioned conditions identified by CMS. Strategic Management offers an array of IA validation services including:

  • Validate corrections of deficiencies identified during CMS full or partial program audits.
  • Provide Subject Matter Experts (SMEs) pertaining to Medicare Part C and Part D programs.
  • Assist sponsors in demonstrating correction of conditions of non-compliance identified in the final CMS audit report and serve as the basis for the CEO attestation that the conditions are corrected and are not likely to recur.
  • Create detailed validation work plans that clearly outline the validation process, timeline, and key milestones.
  • Develop validation work plans that test the effectiveness of the organization’s corrective action plans and whether the organization’s transactions comply with CMS’ requirements.
  • Conduct data integrity testing of universe submissions and validate accuracy and completeness.
  • Compile validation reports detailing findings, i.e., outcomes of sample cases and universes reviewed.
  • Attest to using the Generally Accepted Government Auditing Standards (GAGAS) in our review services.

CMS Audit Preparedness & Remediation:

  • Perform Medicare Advantage and Part D audits that mimic CMS audits.
    • Compliance Program Audit Process
    • Enrollment Disenrollment Audit Process
    • Part C Organizational Determinations Appeals and Grievances (ODAG) Audit Process
    • Part D Coverage Determinations Appeals and Grievances (CDAG) Audit Process
    • Late Enrollment Penalty Audit Process
    • Formulary and Benefit Administration Audit Process (i.e. rejected claims, pharmacy & therapeutics)
    • Agent Broker Oversight Audit Process
    • Outbound Enrollment Verification (OEV) Audit Process
    • Self Disclosure Reporting Special Needs Plans (SNPs) – Model of Care (MOC) Implementation Audit Process
  • Perform focused audits (areas of concern to the organization).
  • Develop and implement monitoring and auditing work plans.
  • Facilitate implementation of corrective action plans (CAPs).
  • Assist with evidencing compliance program effectiveness.

Eligibility, Enrollment, and Disenrollment:

  • Assist with process requirements for incomplete / enrollment requests, denial of enrollment, & disenrollment.
  • Test through enrollment/disenrollment sampling techniques.
  • Perform systems and claims reviews.

HIPAA, HITECH, Security Breach Compliance:

  • Conduct privacy and security risk assessments.
  • Conduct gap analyses to support “Evaluation” standard.
  • Develop and/or revise privacy and security policies and procedures.
  • Design ongoing privacy and security compliance monitoring program.
  • Design and monitor Business Associates Agreement process.
  • Develop and administer HIPAA privacy and security education and training.

Provider Credentialing Audit Services:

  • Conduct performance audits of provider credentialing process of Medicare or Medicaid health plans.
  • Ensure compliance with federal & state contracts and applicable policies and procedures, laws and regulations.

Retrospective Audit of Physician Evaluation and Management Claims:

  • Conduct audit of physician groups on behalf of Medicaid health plans.
  • Provide an interdisciplinary team of auditors, statisticians, and coders.
  • Review accuracy of claims.

Risk Management Services:

  • Conduct risk assessment and risk management engagement, which include:
    • Risk Assessment
    • Risk Remediation
    • Risk Monitoring and Auditing; and
    • Risk Reporting

Sales and Marketing:

  • Evaluate marketing and promotional activities.
  • Assess compliance with federal and state licensure and appointment laws.
  • Develop and administer agent/broker compliance training.
  • Design sales and marketing oversight program.
  • Test through samples and assess compliance criteria.
  • Survey, audit and monitor compliance of marketing and enrollment staff.
  • Conduct field visits and secret shops.
  • Conduct expense reviews of Part C and D expenses related to Medicare marketing requirements.

Corporate Integrity Agreements and Investigations

Independent Review Organization (IRO) Services:

  • Systems reviews.
  • Transactions reviews.
  • Unallowable cost reviews.
  • Arrangements reviews.
  • Claims reviews.
  • Marketing and quality control process review.
  • Secret shops and compliance reviews.
  • Compliance program reviews.

Special Investigation Unit (SIU)/ Fraud, Waste, and Abuse (FWA) Support Services:

  • Analyze claims data and audit.
  • Detect systemic weaknesses.
  • Conduct root cause analysis.
  • Economize on audit resources through valid sampling and extrapolation techniques.
  • Investigate cases.
  • Prepare written policies and procedures.
  • Develop and administer training and education.
  • Design working protocols to coordinate between MCO SIU and corporate compliance program.
  • Assist with FWA auditing, monitoring and risk assessment services.
  • Design/Redesign FWA Program.
  • Conduct quality assurance (QA) assessments.

Managed Care Advisory Services

Advisory Services and Regulatory Analysis:

  • Advisory services in relation to industry trends and current issues (e.g., Affordable Care Act).
  • Medicare and Medicaid and other program specific (e.g., Program of All-Inclusive Care for the Elderly (PACE program) contract interpretation and implementation services.
  • Corporate Integrity Agreement advisory services.
  • State contract compliance assessments (e.g., Medicaid contracts).
  • Reviews and regulatory analyses of local, state federal, and National Committee for Quality Assurance (NCQA) requirements.
  • Development and implementation of compliance programs to meet applicable accountable care organization (ACO) and ACO type regulatory and contractual requirements.

View all Health Care Compliance Services

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