Managing risk and compliance: Medicare

The challenge

Medicare Advantage products and Medicare prescription drug plans (Part D) have provided profitable growth for many payers. However, keeping current with requirements from the Centers for Medicare and Medicaid Services (CMS) in addition to keeping products innovative and cost competitive present formidable administrative and strategic challenges for insurers.

CMS has also changed the way it monitors and enforces compliance and plans will need to be adjusted accordingly. For example:

• CMS now employs a more data-driven approach to oversight. Rather than reviewing all plans on all audit elements, they use data submitted by plans and focus regulatory efforts on outliers.
• CMS has stepped up their identification of non-compliance with more than 40 compliance letters issued at the end of the 2009 annual election period.
• CMS has imposed more intermediation sanctions and civil monetary penalties than in the past, and has published that information on its website for the public and press to peruse.
• CMS has also held plans more directly accountable for their vendors' compliance with delegated duties.

How we can help you

Designing and implementing your Medicare Advantage and Part D plans requires special care so they are profitable, compliant and valuable to your members.

Our cross-functional teams bring together professionals with experience in public and private sectors who understand the stringent and complex regulations that govern how you need to design and implement your Medicare Advantage and Part D plans. We can help you with benefit design and pricing, strategic planning, preparation of applications and competitive bids, mock audit, coding audits, sales and marketing analysis, plan implementation, network development and medical management.

You should choose your vendors including pharmacy benefit managers (PBM) carefully and monitor their transactions for compliance and integrity.

We can help you with vendor oversight and accurate tracking and submission of transactions. Improved management in these areas can avoid severe financial consequences in the form of sanctions, fines and repayments.

Common services include:

• Assessing, designing, constructing and implementing Medicare Advantage and Part D processes to improve operational performance
• Evaluating compliance with Medicare Advantage and Part D regulatory requirements
• Designing short- and long-term strategies for Medicare Advantage and Part D lines of business