Payers operate within a fragmented regulatory environment due to state-specific market conduct regulations and oversight. Payers who face market conduct examinations are subjected to significant scrutiny of key business processes such as sales and marketing, complaint handling, claim processing, underwriting and rating, and cancellations and rescissions. Successful market conduct examinations that satisfy state regulators and meet company objectives are achieved through the effective execution of an examination strategy. As states increase the frequency of collaborative market conduct examination activities (via the use of the NAIC's market conduct uniform exam procedures, market regulation handbook, and standard data calls), payers benefit from proactive assessments of business processes and compliance controls against regulatory standards.
How we can help you
PricewaterhouseCoopers provides comprehensive financial, economic, compliance and strategic advice to companies involved in market conduct exams. We provide a broad range of consulting services to general counsels, chief compliance officers, and outside advisors involved in the planning, execution and resolution of market conduct exams.
We work with payers on essential tasks such as:
- Exam strategy development
- Pre-exam assessments of regulatory compliance controls in key business processes
- Exam support assistance
- Regulatory compliance self-assessments
- Development of processes for accurate and complete data/document productions
- Evaluation of and responses to regulatory criticisms and draft findings
- Design, implementation and assessment of compliance controls to address exam findings
- Statistical design and analysis (e.g., claims)
