Payer services and solutions

Managing risk and compliance: State laws and regulations

Payers operate within a regulatory environment. You must comply with a tangle of state and federal mandates. A hodge-podge of state laws and regulations such as any-willing-provider mandates, prompt payment rules and state-specific market conduct regulations. Keeping track of disparate rules and regulations can be confusing, and complying with them, burdensome.

Increasingly diligent - and more intrusive - regulators scrutinize payer business processes for compliance. State regulators perform market conduct examinations with increasing regularity. These examinations involve significant inspection of your key business processes - sales and marketing, complaint handling, claims processing, underwriting and rating, cancellations and rescissions.

When you face a single-state or multi-state market conduct examination, you need an effective strategy that satisfies state regulators and meets company objectives. This strategy begins with a proactive assessment of business processes and compliance controls against regulatory standards. Risk assessment should be integral to an overall compliance program that anticipates and manages risk, and prepares the organization to respond to examinations, investigations and crises on the state or federal level.

How we can help you

You need to comply with a confusing array of disparate state regulations and evolving mandates. We can help your organization assess regulatory compliance and design effective risk-management programs.

Market conduct examinations are increasingly a fact of life for payers. You should develop a strategy for cooperating with the examinations and quickly resolving compliance shortcomings. We can provide comprehensive financial, economic, compliance and strategic advice to payers confronting market conduct examinations. Our broad range of consulting services help you plan and execute market conduct examinations and quickly resolve the compliance issues they discover.

Common services include:

• Development and support of market conduct examination strategy
• Assessments of regulatory compliance controls in key business processes
• Development of processes for accurate and complete data and document production
• Evaluation of and responses to regulatory criticisms and draft findings
• Design, implementation and assessment of compliance controls