Health Plan Oversight and Compliance
Health Plan Oversight and Compliance

Health Plan Oversight and Compliance 

Managed care is now considered the primary financing and delivery mechanism to manage cost and utilization and to ensure quality health care within the United States. Using our considerable experience with managed care, Myers and Stauffer is in a unique position to assist local, state and federal government health care leaders with the design, implementation, evaluation, and audit of their managed care delivery systems.

Myers and Stauffer provides multiple channels of support to government agencies in the oversight of health plan activities. Our services include oversight and compliance within the management of the state Medicaid managed care programs, the Medicare Advantage program, and government employee and retiree health benefit plans.  We currently work with numerous local and state governments, as well as CMS, to provide audit, consulting, and monitoring efforts related to health plans. This work includes hundreds of health plans, including the largest nationwide health plans, as well as smaller regional health plans.

Medicaid Managed Care

Our managed care team’s audit and consulting services are designed to address the entire evolution of a managed care program, from program design and procurement development to sustained program monitoring and evaluation. Our services address requirements outlined in the Medicaid and CHIP Managed Care final rule, released on May 6, 2016, and the Medicaid and CHIP Managed Care Access, Finance, and Quality final rule, published May 10, 2024. Additionally, our solutions help our clients enhance their ability to develop and monitor managed care programs to not only ensure compliance with federal, state, and industry standards, but also to ensure the program is aligned to achieve the programmatic and health care outcomes desired by all stakeholders. Our Medicaid managed care services include, but are not limited to:

  • Design, Procurement, and Implementation
    • Program development and implementation.
    • Planning and stakeholder engagement.
    • Managed care contract or request for proposal (RFP) development. 
    • Operational support related to CMS negotiations, staffing support, and operational oversight.
    • Readiness reviews and MMIS readiness testing.
    • Policy support related to quality reporting standards (QRS), value based payment (VBP) models, and quality assurance and performance improvement (QAPI) assessments.
    • State waiver and state plan amendment (SPA) consulting and support, including 1915(b) independent assessments.
    • Serving as independent assessor for 1115 demonstration waiver initiatives.
  • Financial Services
    • Medical loss ratio (MLR) examinations.
    • Administrative cost review.
    • State directed payment validation and pre-print development consulting.
    • Capitation payment and third party liability testing.
    • Legislative updates and financial impact assessments.
  • Services Related to Encounter Data
    • Encounter data validation (EDV).
    • External Quality Review (EQR) Protocol 5.
    • Encounter data risk adjustment.
    • Dashboarding.
  • Compliance Consulting and Oversight
    • Network adequacy and access, including secret shopper surveys. 
    • External Quality Review Protocols. 
    • Contract monitoring.
    • Vendor monitoring and oversight, including pharmacy benefit managers (PBMs). 
    • Program integrity audit and oversight.
    • Managed care program annual report (MCPAR) required by CMS.
    • Evaluation of appeals and grievances, prior authorizations, and denial of services.

Medicare Advantage and Prescription Drug Plans 

Since 2009, we have assisted the Centers for Medicare & Medicaid Services (CMS) with the oversight of Medicare Advantage Organizations (MAOs) and Prescription Drug Plans (PDPs) to address financial reporting accuracy; compliance program effectiveness; and fraud, waste, and abuse.

  • Financial-Related Examinations:  Our team has reviewed hundreds of millions of pharmacy and medical claims adjudicated by multiple PBMs, health plans, and Third Party Administrators (TPAs)  to ensure the proper administration of medical and pharmacy benefit plan designs, assess financial solvency adherence to published rules and guidance, and contract compliance. Additionally, we have supported CMS’ efforts to monitor the corrective action plans put in place by the health plans to remedy the identified deficiencies. These examinations have identified areas of non-compliance with CMS guidance, including issues such as improper interpretation of published guidance, technical/systems deficiencies, claims processing and operational deficiencies, staffing issues, and poorly defined or incomplete processes.
  • Compliance and Performance Audits: In partnership with CMS, we have established audit designs, protocols, and procedures for conducting compliance and performance audits in the review of PDPs and MAOs to ensure compliance with Medicare program requirements. In conducting these program audits, we focus on evaluating whether plan sponsors have implemented effective compliance programs. The audits have focus on several core operational areas including: compliance program effectiveness, verification that plan sponsors are properly implementing Part D prescription drug formulary and benefit administration; Part D prescription drug coverage determinations, appeals, and grievances; Part C organization determinations, appeals, grievances, and dismissals; enrollment and disenrollment, outbound enrollment verification; special needs plan model of care; and agent/broker oversight. We have also provided additional services including risk assessments, protocol development, data analysis, low-income subsidy audits, and validation of corrective action plans.
  • Program Integrity: We have worked together with the Center for Program Integrity (CPI) since 2005 to support efforts to identify, correct, and prevent fraud, waste, and abuse in the Medicare Parts C and D programs. Through these efforts, we support CPI with the development and research associated with program vulnerabilities, the identification and recovery of inappropriate payments, and providing subject matter expertise on emerging issues. We worked with CPI to develop the methodology to calculate damages to the Medicare Part D program and have since performed hundreds of damage calculations for law enforcement.

Our experience includes, but is not limited to, each of the following health plans, which may be referred to differently depending upon the program or market:

  • Accountable Care Organizations (ACO)
  • Benefit Administrators
  • Care Management Organizations (CMO)
  • Contracted Entities (CE)
  • Coordinated Care Organizations (CCO)
  • Health Maintenance Organizations (HMO)
  • Managed Care Organizations (MCO)
  • Managed Care Entities (MCE)
  • Medicare Advantage Organizations (MAO)
  • Prepaid Ambulatory Health Plans (PAHP)
  • Prepaid Inpatient Health Plans (PIHP)
  • Prepaid Mental Health Plans (PMHP)
  • Preferred Provider Organizations (PPO)
  • Prescription Drug Plans (PDP)
  • Primary Care Case Managements (PCCM)
  • Program of All-inclusive Care for the Elderly Plans (PACE)
  • Provider Led Entities (PLE)
  • Third Party Administrators (TPA)
  • Dental Plans
  • Transportation
  • Behavioral Health Plans
  • Dual Eligible Plans

Government Employee and Retiree Health Benefit Plans

Myers and Stauffer provides comprehensive audit services of TPAs and PBMs.

These audits ensure the administrators of the employee benefit plan are performing according to their contract, meeting performance guarantees, adjudicating claims consistent with the plan benefit design, and rebates and other credits are appropriately remitted. Our services related to benefit administrator audits include:

  • Data-driven review of 100% of claims.
  • Selecting and testing a statistically valid sample of claims (paid and denied).
  • Ensuring credits, such as subrogation and recoveries as a result of fraud, waste, and abuse and other claims auditing efforts, are accurately reimbursed.
  • Ensuring compliance with performance guarantees.
  • Ensuring compliance with contract terms.
  • Ensuring clinical functions are compliant with laws, regulations and contractual obligations.
  • Analyzing internal audit processes for gaps in comparison to contractual obligation and industry standards.
  • Related services to support monitoring of employee benefit programs include:
    • Pharmacy Benefit Manager Audits.
    • Provider Audits.
    • Member and Dependent Eligibility Audits.