Consulting Services

Audits

Mock CMS Audits look at the areas that CMS is reviewing in the most recent CMS Protocols or Financial Audits. Many organizations have minimal experience going through a CMS audit, or don’t have visibility into their compliance risk.  Organizations that believe that they will be selected for a CMS program audit and/or which may have significant risk within the areas of CMS review, can benefit by Rebellis Group Consultants conducting a “Mock Audit”. The Mock audit will mimic the CMS process in every way except that the Organization will be provided more time to gather information and will be provided with best practices along the way.

Our team can also assist your organization in performing delegation oversight of your brokers, vendors, providers, and other First Tier Entities.  We have comprehensive and flexible audit support packages that can include everything from your annual CPE audits to your pre-delegation and annual delegation oversight audits.  From internal audits, data validation audits (DVA) to independent validation audits (IVA), we have you covered.

Pharmacy Operations

The Rebellis Pharmacy team has many years of experience and deep subject matter expertise to support a variety of project in Medicare Advantage, Medicaid, ACA, and commercial organizations.  Projects include, but are not limited to:

Interim staffing

  • PBM delegation oversight and monitoring

  • PBM contracting, implementation, and audits

  • STARs strategy and implementation

  • Medication Therapy Management (MTM)

  • Part D operations re-engineering

  • Benefits Administration Testing

  • Rejected claims review

  • Formulary administration operations

  • CMS Program Audit support

  • Audit remediation

  • Part D compliance and training

Operations and Plan Implementations

Rebellis consultants have decades of experience creating the most efficient and compliant operations.  Many organizations do not have the controls or visibility in place to prevent and detect non-compliance.  Our comprehensive tools and experts evaluate end-to-end operations to identify compliance and operational risks and provide an actionable plan to remediate and monitor operations.

 

With more than a decade implementing new Medicare Advantage and Part D plans - whether SNP, EGWP, PACE, MMP, or any other plan type - our consultants have the experience and tools to support you from the Notice of Intent through Application and full health plan implementation.

Form interim management to business process redesign, our experts can support all facets of your organization:

  • Call center, enrollment, premium billing and reconciliation

  • Claims processing requirements, including Coordination of Benefits (COB), recovery, and Medicare secondary payer (MSP)

  • Finance and accounting

  • IT infrastructure, vendor integrations, and CMS and State reporting

  • Part C organization determinations, appeals, and grievances

  • Part D coverage determinations, exceptions, appeals, and grievances

  • Marketing and sales

  • Provider/vendor contracting, network adequacy, and management

  • Risk adjustment submissions, reconciliation, auditing, and strategy

Industry Intelligence

From the implementation of CMS' expanded definition of supplemental benefits to the increasing awareness of social determinants of health, the healthcare industry is changing rapidly and will continue to change in the coming years.  We stay at the forefront of the healthcare political and regulatory landscape to provide guidance for effective strategies in this health care era.

Clinical Operations

Rebellis provides exceptional experience to support all phases of clinical operational requirements for development or revision of all programs within a Medicare Advantage plan or product type. We support development of medical management program design to include:

  • Case management program development, stratification of population, and system design support

  • SNP Model of Care development or revision and review, including all policies needed to support best in practice administration of the SNP program

  • Chronic Condition Improvement Program design and management

  • NCQA accreditation assistance

  • Quality Improvement Program development and revision after annual review, with supporting best in class policies and work plan development

  • Utilization Management policies and processes

Marketing Material Review

Because Marketing Material Review is seasonal, many compliance departments find it difficult to accommodate the influx of materials needing compliance review during the months leading up to and during AEP. In addition, inaccurate or incorrect marketing materials pose significant risk to the Organization. In fact, CMS has cited inaccurate materials in many compliance actions over the past few years.

 

Rebellis Group Consultants can serve as the Compliance Marketing Review function throughout the year or during AEP as needed.  The marketing review assistance is provided virtually. 

Data and Analytics

Implementation of cross-functional data collection, identification of critical performance metrics for executive reporting, ongoing expert review of plan analytics, HPMS reporting submission analyses, process review or implementation.

Star Ratings Analysis

Support for development of a best-in-class Star Rating program to support your plan's structure, goals, objectives, and provider/partner relationships for enhanced member and provider engagement and satisfaction.

Executive Project Leadership

Expert guidance of sweeping operational changes or system implementations to drive successful outcomes.

Software Support

Evaluation of external software solutions and RFP assistance, new software implementation support, including technical requirements, configurations and system reporting, analysis and recommendations for optimization of existing systems, and development of requirements for internal system development.

Executive Strategy Consulting

Identification of large-scale implications of inter-department decisions, understanding critical points of failure and impacts on future success, and recommendations for strategic shifts to integrate critical interdependent functions.

Vendor Evaluation

RFP guidance and development, capability evaluation, pre-delegation review, implementation support.

Growth Strategy

Sales channel strategy (mix and distribution), current market evaluation, provider-based marketing strategy development, benefit design strategy, expansion market analysis.

Compliance Officer Advisory Services

Up to 10 hours a month of confidential one-on-one, personalized advisory services across all areas of the business with our team of industry experts.

Need a project not listed here?  Contact us to develop a custom scope of work to fit your business need.