A Medicare Advantage (MA) plan or Part D Benefit is more than simply a “product line” – launching and operating a Medicare Advantage program or Medicare Part D drug program requires focus on the unique details, including operational and compliance requirements of the program, both for the plan itself as well as monitoring its subcontractors.
We help clients with business process engineering for enrollment and reconciliation, claims, pay as Medicare pays, appeals and grievance programs, UM/QI programs, model of care implementation, customer service management and training, provider management and payment systems, subcontractor and vendor contracting and oversight.
For Part D, the term “complexity” is an understatement. ACG assists Part D sponsors to build robust end-to-end business processes and operational policies. ACG assures compliance in areas such as enrollment, grievances, marketing oversight, exceptions/coverage determinations, COB, DIR, PDE management, Part B vs. Part D determination, enrollment and financial reconciliation, delegation oversight process monitoring, and CMS complaint management.
Medical Management and Quality Improvement
ACG’s team assists Plans with Model of Care development and implementation, demonstration program integration, delegate oversight, MA organization determination operations, Medicaid UM programs, compliance, CMS Star measure enhancement and more.
Compliance Review / Mock Audit
Routinely testing a Plan Sponsor’s compliance with regulation and constantly evolving CMS guidance with focus on demonstrating compliance during an audit is a best practice followed by industry leaders. ACG assists PDP and MA-PD plans and plan sponsors through performing targeted or system-wide mock audits and compliance reviews, including audit universe preparation, file review, policy and procedure review and delegation oversight.
We help with MA provider network contracting for all provider types for new programs and Service Area Expansions for CCP, PPO and PFFS Conversions.
ACG assists in evaluation and selection of back-office administration vendors (claims, enrollment and billing) along with project management for implementation.
We can help with application completion, project coordination and management for CCP (HMO/POS), PPO, MA/PD and PDP.
Fraud, Waste and Abuse Program Development
Fraud, Waste and Abuse monitoring for Medicare Part D requires taking steps to minimize both internal and external risks. ACG assists PDPs and MA-PDs in program development to minimize exposure under the False Claims Act. We identify and focus audit programs for internal operations and subcontractors, identify and develop data mining methods for beneficiary, and build-in procedures that assure prescriber and pharmacy fraud is eliminated. The key to success is to implement thorough FWA training programs for Part D staff.
Prescription Drug Event Data Management
Understanding PDE data errors and their financial ramifications along with building tracking and resolution systems requires robust business processes development. ACG can assist in analysis, PBM interface, and training and tracking system development. We help our clients maintain effective PDE error resolution to keep Plan operating costs in check.
Training Program Development
Staff training is critical to effective Part D operations. ACG can assist in development and tailoring of departmental specific training to meet Part D regulatory requirements. Effective grievance management requires broad and succinct training for all externally facing staff. Fraud, waste and abuse training can turn your customer service staff into the front line of defense for fraud.