Managed Care Oversight & Compliance
We provide Medicaid managed care oversight and compliance services to help state Medicaid agencies strengthen health plan oversight, encounter data validation, and program performance. Our team supports the full managed care lifecycle, including program design, procurement, readiness reviews, network adequacy, financial audits, and data analytics.
Supporting Oversight, Performance, and Accountability in Medicaid Managed Care Programs
Medicaid managed care programs are pivotal to delivering services to beneficiaries, and they require strong oversight to ensure payments to providers are accurate, services are accessible, and program requirements are met. As states expand managed care and respond to evolving federal requirements, agencies must monitor plan performance, validate data, and ensure compliance across a complex network of health plans and vendors.
We support state Medicaid agencies across the full managed care lifecycle, from program design and procurement through implementation, oversight, and ongoing performance monitoring in compliance with Centers for Medicare & Medicaid Services (CMS) requirements. Our work provides independent, objective analysis to strengthen compliance, improve transparency, and support effective program administration.
Supporting the Full Managed Care Lifecycle
Effective managed care programs require coordination across each phase of the lifecycle, from initial design through ongoing oversight and improvement.
We support agencies in:
Supporting Effective Managed Care Programs
We work with agencies to strengthen Medicaid managed care programs through independent oversight, data validation, and performance monitoring, supporting transparent, accountable programs that deliver high-quality care while ensuring responsible use of public funds.
Successful managed care programs begin with thoughtful design and well-executed procurement processes. States must navigate complex policy, operational, and regulatory considerations when developing program structures, issuing procurements, and selecting health plans.
We support agencies in designing and procuring managed care programs, including program structure development, Request for Proposal (RFP) support, contract design, and implementation planning. Our work helps establish strong foundations for effective oversight and long-term program performance.
Before program launch, agencies must ensure that managed care organizations are fully prepared to deliver services and meet contractual requirements.
We conduct comprehensive readiness reviews to evaluate health plan operations, systems, staffing, and compliance. Our work helps identify risks prior to implementation and supports continuity of care during program transitions.
Once programs are implemented, ongoing oversight of health plan performance becomes critical. Agencies must monitor compliance, evaluate operations, and ensure that plans meet contractual and regulatory requirements.
We support comprehensive health plan oversight through operational reviews, compliance monitoring, and performance evaluation. Our work provides agencies with the insight needed to manage accountability across managed care programs.
While our managed care work is often focused on Medicaid programs, we also support federal agencies in overseeing Medicare Advantage plans. Our work includes risk adjustment data validation, encounter data review, and compliance support aligned with CMS audit and oversight requirements.
Effective oversight depends on accurate, reliable data. States must validate both financial and encounter data to support rate setting, compliance, and program monitoring.
Financial Data Audits
We conduct independent audits of managed care financial data, including medical loss ratio (MLR) validation and administrative cost review, to ensure accuracy and compliance with federal requirements.
Encounter Data Validation
We validate and analyze encounter data to ensure completeness, accuracy, and alignment with financial and operational reporting.
Ensuring that members can access needed services is a core responsibility of Medicaid managed care programs. Federal requirements continue to expand expectations for network adequacy and access monitoring.
Network Adequacy & Access Monitoring
We evaluate provider networks, access standards, and compliance with federal and state requirements, including time, distance, and appointment availability.
Secret Shopper Surveys
We design and conduct independent secret shopper surveys to validate provider availability, appointment wait times, and provider directory accuracy, supporting new federal access requirements.
Ongoing oversight requires more than individual reviews — it requires the ability to monitor performance across plans, programs, and time.
We develop data analytics and performance monitoring solutions that integrate data from multiple sources into actionable insights. Our dashboards and reporting tools help agencies track compliance, identify trends, and support informed decision-making.
Effective managed care oversight requires more than monitoring performance and compliance — it also requires identifying, analyzing, and addressing program integrity risks across health plans and delegated entities.
We support state Medicaid agencies in strengthening program integrity within managed care environments through targeted risk analysis, data-driven review, and independent evaluation of health plan and subcontractor controls. Our work helps agencies identify potential fraud, waste, and abuse risks, evaluate anomalies in billing and utilization data, and coordinate oversight activities across managed care and fee-for-service environments.
Medicaid managed care programs increasingly play a central role in delivering long-term services and supports (LTSS), including home and community-based services (HCBS). States must ensure that managed care organizations effectively coordinate care, maintain adequate provider networks, and meet access and quality requirements for these populations.
Managed care programs may also operate alongside other delivery models, such as the Program of All-Inclusive Care for the Elderly (PACE) model, requiring coordinated oversight across multiple systems.
We support agencies in aligning managed care oversight with broader LTSS strategies, ensuring consistency, accountability, and effective service delivery across programs.
Why Agencies Hire Myers & Stauffer
Managed care oversight requires coordination across financial, operational, and clinical areas. Our integrated approach connects data validation, compliance monitoring, access analysis, and performance evaluation to provide a comprehensive view of program performance.
We tailor our approach to each state’s program structure, regulatory environment, and oversight priorities, thereby ensuring that agencies have the tools and insight needed to manage complex managed care programs effectively.
Our managed care services are grounded in extensive experience supporting state Medicaid agencies across diverse program structures. We bring:
Our managed care services support:
Connect With Our Team
Partner with experts who understand the complexities of health and human services programs. Let us guide your organization through the industry’s unique challenges and opportunities.
Judy Hatfield, CPA
Member
Email:jhatfield@mslc.com
Phone Number: 816-957-6310
Email: ksorensen@mslc.com
Phone Number: 919-829-7429
Matthew Varvaris, CPA
Principal
Email: mvarvaris@mslc.com
Phone Number: 208-378-1400
Janae Jensen, CPA
Member
Email: jjensen@mslc.com
Phone Number: 816-957-6280
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