State and Federal Investigations

  • Root Cause and Impact Analysis
  • Independent/Third-Party Review
  • Issue Remediation

Medicare and Medicaid Requirements

  • Monitoring Against Contract Requirements
  • Root Cause and Impact Analysis
  • Issue Remediation

Representative Experience Includes:

  • Conducted quality monitoring testing to evaluate the effectiveness of enrollment, billing, coverage determinations, and appeals related systems and processes against key Medicare requirements

  • Developed Medical Loss Ratio and encounter submission methodologies in close collaboration with core functional areas (e.g., claims, IT, provider network, finance) that were pivotal in federal settlement with Department of Justice

  • Collaborated with internal and external counsel to support the Department of Justice's subpoena requests, draft disclosure letters to and participate in calls with the U.S. Attorney's office

  • Enhanced contractual reporting processes resulting from ambiguous guidance, incomplete data from providers, capitated encounters, and other operational issues