Regulatory and Compliance.

Regulatory and Compliance services are driven by enforcement and oversight activities by Federal and State regulatory agencies. Over the last several years, health plans and managed care companies have faced increasing regulations and mandates at the same time premiums and margins are under pressure. Changing regulatory requirements result in changes to business processes, business rules and systems which require constant monitoring and oversight. Our professionals have the expertise and the experience to address these issues while creating competitive advantages through practical and efficient solutions.

Services

Section 111 Mandatory Reporting and Medicare Secondary Payer (MSP): Section 111 requires Group Health Plans (GHPs) and liability insurers to submit data to CMS to identify individuals for whom Medicare is the secondary payer. HealthScape Advisors helps clients comply with the recent requirement by offering the following services:

  • Compliance assessments
  • Process enhancements
  • Outsourced reporting
  • MSP corrective actions and disclosures
  • Claim payment quantifications and analysis

Medicaid Encounter and Data Reporting: Managed care organizations must comply with contract requirements related to encounter and data reporting for each respective State Medicaid agency. In order to reduce the risk of noncompliance, HealthScape Advisors offers services related to the following:

  • Encounter reporting remediation
  • Process redesign and enhancement
  • Government disclosures
  • Mock audits

State Mandates and Oversight: State mandates impose strict requirements that health plans offer coverage or cover certain benefits, patient populations and providers. Plans must also deal with strict requirements related to prompt payment of claims, prudent layperson requirements, retroactive rescission, and many other state mandates. To ensure compliance with these mandates, HealthScape Advisors offers services related to the following:

  • Market conduct readiness and risk assessment
  • Corrective actions
  • Voluntary disclosures
  • Mock audits

Medicare Advantage and Part D: The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage and Part D plans to comply with a variety of regulations and mandates. To assist clients with achieving and monitoring compliance, HealthScape Advisors offers services related to the following:

  • Corrective actions
  • Risk adjustment remediation
  • Delegation oversight
  • Complex claims, encounters, and enrollment analysis
  • PDE reconciliations
  • Data validation readiness assessments
  • Part D PBM reviews and assessment
  • Formulary rebate reviews

HealthScape Advisors Difference

  • Extensive experience and knowledge of regulatory requirements
  • Seasoned professionals with experience navigating highly visible and time sensitive situations
  • State of the art data analytics to quickly identify issues and root causes
  • Extensive experience presenting results and related support to regulatory oversight agencies
  • Established track record with CMS on corrective actions
  • Established thought leader related to MSP and Section 111

Representative Experience

Section 111 Mandatory Reporting and Medicare Secondary Payer

  • Our professionals performed a gap assessment of a large health plan's current Section 111 practices to CMS requirements. Gaps were identified and prioritized and recommendations were made for resolution. The health plan utilized the recommendations for best practices and formulated Section 111 workgroups to resolve identified gaps.
  • Our professionals were engaged by a mid-size health plan to quantify and help resolve issues with Medicare Secondary Payer practices. All mistaken payments by Medicare were quantified, determined the root cause of mistaken payments and assisted with a voluntary disclosure to CMS. The client successfully corrected the root cause of the issue and repaid CMS for historical mistaken payments.

Medicaid and Encounter Data Reporting

  • Our professionals assisted a large health plan to improve its encounter submission and reporting process related to numerous state Medicaid contracts. Our services included program management surrounding short-term encounter issue remediation and long-term system enhancement initiatives. Additionally, we identified root causes related to major issues in the encounter submission process, which involved investigating drivers of degradation to quality, completeness, and accuracy, and developing solutions to address the underlying issues. As a result of our involvement, the health plan realized a measurable decrease in costly remediation efforts, improved the efficiency and integration of the encounters process, developed improvements to its supporting systems and controls, and ultimately reduced the risk of non-compliance with state regulatory agencies.

State Mandates and Oversight

  • Our professionals assisted a large health plan quantify and remediate underpayments related to a state mandate on emergency room ("ER") payments. Utilizing our extensive data mining abilities, we identified the ER claims that were incorrectly paid according to the mandate. Based upon our analyses, the impacted claims were re-priced at the providers' contracted rates, outside of the claims adjudication system.
  • Our professionals assisted a large health plan that identified issues with claims payment accuracy for members with Pre-Existing Conditions. A detailed statistical claim sample was provided for members with a Pre-Existing Condition in order to comply with the State insurance commissioner's request. As a result, the client was able to avoid audit and identify the root cause of the issue.
  • Our professionals assisted a large health plan identify various issues related to state prompt pay requirements. Our work included root cause analysis, segregation of "clean claims", and quantification of prompt payment interest due on a provider by provider basis. As a result of our work, the client was able avoid audit through a voluntary disclosure and ensure that the proper basis was documented for claims that were not "clean" under the state guidance.

Medicare Advantage and Part D

  • Our professionals supported a Part D health plan with a review of the company's Part D submission processes. The review consisted of reconciling multiple years of claims data to their PDE Submission files, conducting interviews with key staff to gain understanding of the company and their PBM's process as well as identifying trends and areas of risk. The Part D plan implemented best practices based upon the findings and recommendations.
  • Our professional assisted outside counsel of one of the largest PDP contractors in conducting a comprehensive audit of all enrollment and disenrollment processes. The work also included reconciliation of CMS to plan eligibility records across five different data systems including vendors. The issues arose from CMS received member complaints related to potentially fraudulent enrollment/disenrollment of members.