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Managed Care/Government Health Insurance Programs

Effective compliance with federal and state managed care mandates and guidance is essential in today’s highly scrutinized and regulated environment. In addition, healthcare reform legislation, such as the Affordable Care Act, has created many new regulatory risks, as well as new business opportunities, for managed care companies. FTI Consulting helps clients navigate this dynamic regulatory environment and provides services to develop, implement and manage effective compliance and operational programs to address these risks and opportunities.

To compete in such a competitive and highly regulated marketplace, we help managed care companies of all sizes and types effectively structure, administer and protect their business, reputation and standing. Our services address critical areas such as litigation, information technology, performance, reputation, transactions, governance and compliance, and risk management.

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Our experts have held senior executive positions in the managed care, pharmaceutical benefit and legal compliance industries. FTI Consulting managed care team members — including former managed care and Medicare compliance officers, executives, healthcare auditors, statisticians and clinicians — have been engaged as experts in some of the largest and most publicized litigation matters in the managed care industry and are recognized as industry experts that external and internal managed care counsel look to for litigation support.  

Our Industry Offerings

Compliance Services » Government Programs »
Audit Services » Operational Improvement »
Pharmacy Benefit Manager (PBM) Services » Investigations & Litigation Services »

Compliance Services

  • Risk assessments
  • Audit and review of STAR rating domains and measurements
  • Design and implementation of compliance programs
  • Compliance program effectiveness audits  
  • Development and execution of internal auditing and monitoring programs, including co or outsourcing
  • Corrective action plan preparation
  • Independent review organization services for CIA compliance
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Government Programs

  • Government contract application preparation for all Medicare and Medicaid contract types
  • Centers for Medicare and Medicaid Services CMS/DHS site visit/audit preparation
  • Medicare and Medicaid general and specialized training module development and delivery
  • Sales/marketing/broker oversight and field testing, including marketing surveillance and secret shopping
  • CMS Medicare Part D Chapter 9 fraud, waste and abuse analyses
  • Complex claims and encounter, enrollment and clinical data reporting production and analysis
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Audit Services

  • Data validation audits using CMS specifications for all required reporting measures CMS financial activity audit support
  • Enterprise risk management
  • Mock CMS audit of all Medicare Advantage and Part D contract types, including the following areas
    • Enrollment/disenrollment
    • Marketing and sales
    • Claims processing/coordination of benefits
    • Coverage determinations, appeals and grievances
    • Quality and utilization management
    • Pharmacy access, MTMP, formulary, drug utilization review and P&T committee
    • First tier and downstream entity contracts
  • Review of Medicare complaint tracking module data and follow-up procedures
  • Clinical audits of HCC/RXHCCs and mock RADV audits
  • Delegation oversight and audit services
  • State DOI market conduct audit support
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Operational Improvement

  • End-user assessment of claims, enrollment, payment and clinical systems
  • Medicaid management information systems review and validation
  • Benefit configurations testing for medical and pharmacy claims/enrollment
  • Workflow, SOP and desk reference material development for all core health plan functions
  • Interim management of functional areas
  • Large-scale system implementation project management
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Pharmacy Benefit Manager (PBM) Services

  • Formulary administration audits
  • 100 percent electronic claims re-pricing
  • Detailed claims sample testing
  • Formulary rebate reviews
  • Process review of all PBM operational areas
  • PBM-related entity administrative services valuations
  • PDE reconciliation
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Investigations & Litigation Services

  • Assistance with internal and external investigations
    • Board/special committee investigations
    • DOJ/OIG investigations
    • State Medicaid agency investigations
    • External fraud investigations and coordination with law enforcement
    • SEC and statutory reporting issues
  • Consulting and expert witness testimony for health plans and PBMs and their counsel
    • Claims/billing disputes
    • Pricing disputes
    • Prompt payment disputes
    • Other contractual disputes (e.g., rebate and fee issues)
  • Document/discovery management
  • Complex medical and pharmacy claims analysis
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Back to Healthcare

Medicare Audit Preparation Services

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capabilities

FTI can assist Medicare health plans in preparing for challenging CMS audits

PBM Evaluation and Audit

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capabilities

FTI are experts in evaluating the performance of PBMs

Data Validation Contractor Services

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capabilities

FTI is an experienced Medicare Advantage and Part D DVA Contractor

Managed Care Advisory Services

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capabilities

FTI can assist clients on all aspects of managed care operations

Key Contacts
Kenneth J. Barker Senior Managing Director Forensic & Litigation Consulting Contact »
Michael Biggs Senior Managing Director Corporate Finance Contact »
Margaret E. Guerin-Calvert Senior Managing Director Forensic & Litigation Consulting Contact »
Charles D. Overstreet Senior Managing Director Forensic & Litigation Consulting Contact »
Liz Shanahan Senior Managing Director Strategic Communications Contact »
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