Managed Care Services | Capabilities | FTI Consulting | Pharmacy

Managed Care Services

Health Solutions

October 13, 2015

FTI Consulting managed care and government program experts help health plans implement their strategic visions in today’s shifting regulatory and payment environment. With 20 years of experience in government programs, we offer Medicare and Medicaid health plans and their related entities, pharmacy benefit managers and their counsel a comprehensive set of services designed to identify and rectify compliance and operational issues.

Compliance and Audit Services
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 in the form of the Affordable Care Act (ACA) has created many new regulatory risks and business opportunities for managed care companies. FTI Consulting can help you navigate this dynamic regulatory environment and develop, implement and manage effective compliance programs to address these risks. Our services include:

  • Mock CMS Compliance Program Effectiveness and Program Audits performed in real time for the key risk areas of:
    • Formulary administration and transition fills
    • Enrollment/dis-enrollment
    • Agent/broker oversight and outbound enrollment verification
    • Coverage and organization determinations, appeals and grievances
    • Quality and utilization management
    • Pharmacy access, MTMP, formulary, drug utilization review and P&T committee
    • First tier, downstream and related entity contracts and oversight
  • Immediate and 90-Day CMS Corrective Action Plan (CAP) 
  • CMS CAP remediation and validation 
  • Audit and review of STAR rating domains and measurements 
  • Development and execution of ongoing internal auditing and monitoring programs 
  • Data validation audits using CMS specifications for all required reporting measures 
  • CMS financial activity audit support 
  • Clinical audits of HCC/RXHCCs and mock RADV audits

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