Government Contract Compliance
Government health care programs, including reform and expansion under the Affordable Care Act, are key drivers of growth for today’s payers. When properly designed and implemented, these programs, including involvement in the various federally and state-administered exchange markets, offer a strong platform for market growth and product diversification. However, when incorrectly built or implemented using differential commercial models and processes, the programs can lead to constrained market expansion and loss of members and can set off a wave of compliance and enforcement actions.
The Centers for Medicare and Medicaid Services (CMS) expects improved and sustained clinical and administrative quality and access to care and service coupled with compliant systems and processes. The consequences of non-compliance — erosion of plan value and market prominence — also have been articulated in highly publicized compliance and enforcement actions.
The FTI Consulting managed care and government program industry experts have worked in government programs for more than 20 years. In the current shifting regulatory and payment environment, these professionals support Medicare and Medicaid health plans (and their related entities, pharmacy benefit managers, and their counsel) with a comprehensive set of services designed to identify and rectify compliance and operational issues and help health plans achieve and implement their strategic visions.
Our service offerings include:
Mock CMS compliance program effectiveness and program audits performed in real time for the Medicare Advantage and Part D risk areas of:
- Formulary and benefit administration and transition fills
- Agent/broker oversight
- Claims processing/coordination of benefits
- Coverage determinations, appeals and grievances
- Quality and utilization management
- First-tier and downstream entity contracts and oversight
- Annual risk assessments
- Immediate and 90-day CMS Corrective Action Plan (CAP) development
- CMS CAP remediation and validation
- Audit and review of Medicaid Advantage Star Rating domains and measurements
- Development and execution of ongoing internal auditing and monitoring programs
- Department of Human Services site visit/audit preparation for Medicaid plans
- Data validation audits using CMS specifications for all required reporting measures
- Clinical audits of HCC/RxHCCs and mock risk adjustment data valuation audits