Health Care Payor Compliance Consulting

Our skilled advisors are seasoned professionals who have worked in the managed care industry as compliance professionals, legal officers and operations leaders. We can provide counsel across the payor spectrum including commercial, marketplace, Medicare and Medicaid lines of business.

Our team can assist with the following:

• Developing compliance programs based on the CMS core principles for Medicare and Medicaid programs
• First Tier, Downstream and Related Entities (FDRs) risk tiering, monitoring and oversight
• Advise on credentialing programs, organization and oversight
• Delegation oversight programs including risk management, routine monitoring and regular oversight
• Conduct Compliance Risk Assessments customized to your business
• Audit preparedness, risk mitigation and corrective action plans for CMS audits, state Medicaid agency audits, delegation oversight audits, External Quality Review Organization audits, etc.
• New and innovative program assessment and set-up
• Medicare marketing research and advice
• Creating and managing an operational risk management program
• Governance establishment and operation (executive oversight committee, vendor oversight committee, credentialing committee, peer review committee, member and physician advisory committees, policies and procedures committee)
• Provider contracting, including complex managed care relationships and value-based purchasing
• Provider fraud detection and remediation
• Monitoring of regulatory changes including the Affordable Care Act and No Surprises Act
• Insurance carrier and related entity (third-party administrators, utilization review agents and claim adjusters) licensure and expansion
• Insurance holding company act compliance and regulatory filings
• Accreditation advice and counseling