Operational Reengineering and Optimization Consulting

Successful MA plans are proactively taking steps to reduce paperwork, contain administrative costs and improve operational processes. You can join these plans by focusing on optimizing member service, enrollment, coordination of benefits and claims processing. Meanwhile, you need to keep an eye on ever-changing compliance requirements.

Compliance

Does your compliance program ensure your processes, policies and procedures are updated to correspond with the changing guidelines? Are your operations consistent with your plans?

A compliance strategy is a proactive investment that really pays off in the case of an audit. Our consultants are very knowledgeable about current compliance guidelines and how to conform to them. We can conduct operational reviews and gap assessments across your business, from sales and member services to medical management and reporting. Our consultants also help you define and implement compliance or corrective action plans, build employee training programs, conduct mock audits, perform site reviews and offer audit preparation services, Part C and D reporting and Prescription Drug Event audit analyses.

We worked with an MA plan to conduct an intense program review, gap assessment, and policy and procedure development after they received adverse CMS audit findings on more than 80% of their program measures. As a result, the organization was successfully rehabilitated and all CMS sanctions were dropped.

People, Process & Technology Evaluation & Optimization

Are your operational efficiency initiatives driving the cost efficiencies you expected?

Identifying your largest cost drivers and highest transaction volumes—key areas to target for improvement—will point you toward smart investment strategies. We can help leverage data to define those areas with the highest return.

Based on the findings, our team provides operational support to bring efficiency to your product implementation, enrollment, member services, benefit coordination and claims management processes. We know how to effectively implement new products to meet deadlines. Our enrollment and claims management assessments address process shortfalls, including Medicare Secondary Payer and enrollment reconciliation. And, we consistently enhance member service centers to attract and retain members and manage operational costs.

We helped a Fortune 50 payer develop a customer service organization strategy that drove $11.6 million to the bottom line through reductions in inbound calls, training costs and average handle time as well as increases in cross selling agent productivity and call quality.