Medicare/Medicaid Compliance, FWA and Audit Services


Solid Benefit Guidance (SBG) will help you navigate the changes to the government healthcare landscape; Our expertise focuses on assisting health plans with compliance, audits, operational excellence and interim staffing.

We understand the challenges health plans face with ever changing regulations, demands on infrastructure to support and the requirements for evidence of adequate vendor oversight. There has never been a more critical time for health plans to have a “true consultant/audit partner” to work collaboratively with on these challenges. Our staff has served as lead auditors in multiple CMS Compliance Program Audits and have participated, as a group, in more than 150 audits. 

The team at Solid Benefit Guidance will give your company the attention it deserves while delivering top notch results in a timely manner.

We are considered subject matter experts in the areas of:

Compliance

The healthcare landscape is continuously changing with new guidance on both the Federal and State levels. It is difficult for Health Plans to keep abreast of all the changes and stay in compliance. CMS and the States have increased their scrutiny of Health Plan compliance and audit programs, and have focused their enforcement efforts in this area. Our team understands the business challenges this impedes on health plans and have the subject matters experts to support the following:

CMS Mock Audits

Conducting mock audits, based on current CMS Audit Protocols, is the most significant activity a health plan should invest in to ensure audit readiness and proper First Tier Downstream and Relate Entity (FDR) delegate oversight. SBG will assist with the universe pulls, ensuring data integrity, and will assimilate CMS protocol. In addition, we will provide training and coaching to fully prepare staff for an actual CMS audit. A formal report will be provided with detailed remediation actions for issues of non-compliance and best practices.

CMS Audit Engagement

Should you be selected for a CMS Audit, SBG brings a “hands on” approach immediately. Our scope of service encompasses; universe pulls and quality checks, review of disclosed and self-identified issues and Beneficiary Impact Analysis (BIA), coaching of staff and onsite audit support during an actual CMS audit. We will work with the appropriate business owner on any Corrective Action Plan required as a result of observations, CAR’s or ICAR’s. Finally, we will perform a validation audit to ensure that all issues have been remediated, prior to CMS validation.

Regulatory Compliance Support

SBG understands that the volume of regulatory guidance and HPMS memos that health plans receive can be very overwhelming and difficult to manage. Our team reviews key Medicare/Medicaid regulations and other CMS guidance and can provide you with summaries, tracking mechanisms and interpretation. We can support you with implementation of operational processes required, and policy and procedures as needed. Should changes impact an FDR, we can assist in building oversight of these changes into your Vendor Oversight Program.

Compliance Program and Policy and Procedure Analysis

SBG can evaluate the effectiveness of your current compliance program or assist in the development and implementation of one. We can conduct a gap analysis of your policy and procedures and assist in revision and creation of any deficiencies. We can train staff on policy and procedure writing and will ensure that policies and procedures adhere to operational processes within the organization while being compliant with current guidance.

Rejected Claims Review

CMS expects Medicare health plans to conduct a regular reject claims review to ensure that their CMS approved formulary is being administered correctly. SBG has a state of the art rejected claims review product. < Click To Learn More >

CMS Applications

SBG can support you with all types of CMS applications; MAPD, PDP, EGWP or MMP. We have a clear understanding of CMS’ expectations in order to ensure a successful application process.

Interim Staffing

SBG has experienced professionals in both compliance and pharmacy that can serve as temporary staff to assist you during staffing resignations, leave of absences, organizational growth periods or operational issues requiring additional hands.

FDR Oversight/Auditing and Monitoring Programs

FDR Oversight Program

Adequate oversight of First Tier Downstream and Related entities is one of the focal points of CMS. SBG can support health plans in conducting a thorough risk assessment of their FDR’s. We will then utilize the risk assessment to build an effective and robust oversight auditing and monitoring program of these vendors. SBG can also conduct the auditing and monitoring on behalf of the health plan.  We follow up with a detailed summary report to be presented to Compliance Committee and/or other committees. SBG will work collaboratively with health plans to adjust programs as needed based upon areas of risk that are identified throughout the year.

Internal Auditing and Monitoring Program

SBG can assist you in developing and implementing a customized auditing and monitoring program. Each program will be based upon an internal risk assessment. We will give you the tools, templates workflows and training needed to ensure that each program is administered consistently across the organization. SBG can also act as temporary staff for conducting the auditing and monitoring activities within the organization and will provide detailed summary reports to be presented to Compliance Committee and or other committees. SBG will work collaboratively with health plans to periodically adjust the program on newly identified risks.

CMS Mock Audits/Validation Audits

CMS Mock Audits

Conducting mock audits, based on current CMS Audit Protocols, is the most significant activity a health plan should invest in to ensure audit readiness and proper First Tier Downstream and Relate Entity (FDR) delegate oversight. SBG will assist with the universe pulls, ensuring data integrity, and will assimilate CMS protocol. In addition, we will provide training and coaching to fully prepare staff for an actual CMS audit. A formal report will be provided with detailed remediation actions for issues of non-compliance and best practices

CMS Validation Audit

In the 2016 Call Letter CMS clarified that Plan Sponsors should engage with external auditors to validate all findings identified as part of a CMS Program Audit have been corrected.   SBG will work with you to review documentation, pull samples and confirm that corrective actions have been completed and meet CMS expectations. A final validation audit report will be provided to share with CMS.

Fraud, Waste and Abuse

Fraud, Waste and Abuse

We will review and evaluate your current FWA program and your PBM’s program to ensure you are in compliance with current federal and state regulations.

The thorough FWA review by Solid Benefit Guidance will evaluate the following in order to confirm compliance:

  • Analytics
  • Timeliness
  • Reporting requirements
  • Documentation
  • Investigation process
  • Support PBM review and meeting

 

 

 

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