Compliance Programs

Compliance = building the right process (not just digging up dirt)

Medicare Advantage, Part D and Medicaid Plans

Compliance requirements are ever expanding. ACG’s compliance team assists Plans with:

• Compliance risk assessments

• Compliance program development

• Design and implementation of key monitoring metrics and audit programs

• Development of effective staff training programs

• Fraud, Waste and Abuse program development and implementation

• Beneficiary sales, EOC and ANOC material review

• Grievance and appeal program training

• Sales and marketing training and oversight

• First Tier, Downstream and Related Entity (FDR) delegate oversight

• Reporting and documentation of compliance action

• Data sourcing for development of compliance and operations metrics

• CTM Process and Resolutions

ACOs

ACG supports Accountable Care Organizations in implementing effective compliance programs that identify and mitigate risk. ACG’s ACO compliance model focuses on:

• Risk identification

• Staff and provider training

• Data submission accuracy for beneficiary assignment and GPRO quality data

• Monitoring of opt-outs

• Beneficiary materials and marketing

• Data security, use of data and oversight of contractors

Qualified Health Plans (QHP) and Exchange Compliance

Health Exchange and Qualified Health Plans (QHPs) exist in an environment of elevated government oversight of their commercial products. A strong compliance program is not only required to compete on the health exchanges but also is key to financial and operational success.

ACG has broad experience in the implementation of government-regulated programs and can support QHPs in developing and implementing key compliance and monitoring processes for the complex QHP environment.