Your Goals, Meet Our Expertise
Segal Medicare Experts is a premier firm specializing in Medicare Advantage and Part D industry. We work with Medicare Advantage leaders in Health Plans, Field Marketing Organizations and Provider Groups who want to build effective solutions to achieve optimal results.
Our Subject Matter Experts (SMEs) have in-depth knowledge of the Centers for Medicare & Medicaid Services (CMS) programs, policies, and regulations through working as both consultants and former regulators. Our team is 100% dedicated to the Medicare Advantage and Part D industry, which allows us to bring both expertise and experience to your specific project.
At SME, we understand that each organization has its distinct goals, and we are committed to listening first, and then planning the project specifically for you and your organization. Our team uses a 360-degree view acknowledging all aspects of the company: people, processes, technology, and governance. This ensures taking into account all moving parts so we can create effective solutions. Our team delivers results by using their insights to facilitate feasible and viable solutions for success.
We are ready to get started.
Call me at: 562 334 7980
Hours: Monday to Friday, 8am to 8pm (PST).
CEO, Segal Medicare Experts
Have you completed the required annual CPE Audit?
Let us provide you a proposal that makes this requirement quick and easy!
Contact UsOur Expertise
SME specializes in the development, implementation, and management of people, processes, technology, and governance. Whether your organization is looking to augment your existing program or launch a new program, our team has in-depth knowledge of CMS policy, regulations, guidance and industry best practices.
At SME, we employ a six-phase approach to success. Throughout the process, we work with your team of in-house and external stakeholders to identify gaps, streamline workflows and benchmark against world-class programs. Establishing KPIs and performance metrics is an essential step for evaluating the effectiveness of operations.
Generally, the following is our process for most projects.
Engage
Evaluate
Plan
Implement
Measure
Support
We invite you to contact us as soon as possible to discuss your specific needs.
Health Plan Solutions
Our expertise includes all aspects of Medicare Advantage Health Plans. Our team is 100% dedicated to the MA and Part D industry, which allows us to bring both proficiency and experience to each project. Our team has an in-depth knowledge of CMS policy, regulation, and industry best practices. Our Client engagements include projects such as, but not limited to, the following:
Audits
- Agent and Broker Audits
- Audit and monitoring work plans
- CMS Audit Coaching
- CMS Audit Preparation
- Compliance Program Effectiveness (CPE) Audits
- Coverage Determination, Appeals and Grievances (CDAG) Mock CMS Audits
- Compliance Progam Effectiveness Audit
- First tier monitoring and auditing
- Operational Audits
- Organization Determinations Appeals and Grievances (ODAG) Audit
- Special Needs Plans (SNP) Model of Care (MOC) Audit
- Website Audits
Clinical
- Model of Care Creation/Audit
- NCQA Audit Preparation and Assistance
- Star Ratings Analysis and Improvement Strategy
- Utilization Management Reviews
Compliance
- Annual risk assessment
- Investigating Fraud and Abuse
- Pre-Delegation Due Diligence
- On Call - Dial a Friend
- Regulatory guidance and resources
Executive Coaching
- Communication Process Re-engineering
- Conflict Resolution
- Organization Development
- 360 Degree Reviews
Operations
- GAP Analysis
- Interim Management (Grievances & Appeals, Enrollment, Claims, UM)
- Interim Staffing
- Interviews for New Employees
- MA-PD/Part D Applications
- New Plan Implementation
- Process Re-engineering
- Call Center Tools and Training
- Create Provider Manual
Pharmacy Part D
- Formulary Review
- Interim Pharmacy Director
- Part D Monitoring and Oversight
- PBM Due Diligence
- PBM Implementation
Provider Network
- Creation of Network Management Tools
- Creation of Provider and Facility Tables
- Network Access Reviews
- Network Development
- Provider Directory Audits
Sales & Marketing
- Benefit Design
- Brand Awareness
- EOC, SBs, ANOCs creation/review
- FMO Contracting
- Interim Sales & Marketing Management
- Marketing Material Audit
- PBP Assistance
- Strategy
Training
- Medicare Advantage Functional Area Training through UL Pure Learning
- MA/Part D Computer Based and Live Training
- Side By Side Training
- Hands on training
Provider Solutions
With the shift to value-based care and the rise of consumerism in healthcare, providers can no longer afford to rely solely on traditional approaches to improve quality. To compete in an ever-changing industry, providers must address a need that's eluded them, sometimes for years: motivating their historically non-compliant, disengaged patients. No matter how complex your business needs, we have the experience and ability to deliver the answers you need. Let us help take decisive action and achieve sustainable results.
- Provide CMS requirements training
- Review and determine timeliness for CMS required universes (organization determinations)
- Create and/or revise a compliance program in accordance with CMS requirements
- Conduct ongoing monitoring reviews and audits, such as organization determinations (denials, authorizations), and marketing material
- Participate on conference calls with clients, and State or Federal government regulators
- Respond to clients or CMS compliance requests
- Interim Management
- Consumer Assessment of Healthcare Providers and Systems (CAHPS®) strategy and training
Marketing Solutions
We can ease the stress by developing or reviewing your marketing materials. Training is essential to attain the required compliance. FMOs, we can provide a Compliance Officer to implement and guide the day-to-day operations and your compliance program.
- Create and maintain sales agent manual, an effective tool with all the information required at their finger tips
- Create and review marketing materials, advertisements, TV ads and Facebook posts
- Create and/or revise marketing training program for the marketing and advertising agencies
- Establish policies and procedures to document expectations and compliance
- Create an efficient and easy to implement audit program from the ground up, or from your existing program
- Conduct FMO, Agent, Broker Audits
- Effective project management and creation/review of ANOCs, EOCs, and SB content by using PBP data
- Establish policies and procedures to document expectations and compliance
- Interim marketing management
- Investigate sales allegations
- Provide regulatory guidance and resources
Agent/Broker/FMO Solutions
- One-stop shop for asking all questions and interpretation of CMS regulations and guidance
- Complete annual audits to ensure achieving a positive and consistent outcome
- Conduct a gap analysis to identify risk areas to mitigate potential non-compliance
- Conduct secret shopping to ensure consistent and compliant sales activities
- Create and/or revise marketing training program for the marketing and advertising agencies
- Establish policies and procedures to document expectations and compliance
- Interim marketing management
- Investigate sales allegations
- Provide regulatory guidance and resources
SME Of The Month
Our SME team all do exceptional work. Each month we select one team member for their outstanding performance, dedication, and achievement.
SME Liza Arias
Liza Arias is a seasoned healthcare executive with over 20 years of experience establishing, developing, and motivating results-oriented audit and compliance teams for healthcare operations. She has experience in all aspects of Medicare plan operations, compliance, marketing and sales oversight, ethics, and privacy including executive management, associate training and development, data analysis and reporting.
Prior to working as a consultant, Liza held a management position with a Special Needs Plan (SNP) where she was responsible for the organization's day-to-day operations, benefit design and bid development, call center, enrollment, and appeals and grievances.
Liza has also served in various roles with several Medicare Advantage organizations in the greater Los Angeles markets in the areas of call center, credentialing, regulatory compliance, SIU, and internal audit.
Liza's areas of expertise and focus are new plan implementations, MA, and SAE applications, creating and implementing compliance programs for the healthcare industry, vendor demos and systems implementation, call center operations, grievances, and appeals, creating detailed compliance and operations trainings, and developing policies and procedures.
Liza also brings experience with CMS program audits during her time with Medicare Advantage organizations and in her current role as a consultant.
Frequently Asked Questions
Recent Client Questions and CMS Answers
If a plan utilizes InterQual's platform for internal coverage criteria, is it CMS' expectation that the plan's UM Committee approve the criteria developed by InterQual? Or review and approve using "InterQual"?
Hello Shelley,
As outlined in the regulation at 422.137, the UM committee must "At least annually, review the policies and procedures for all utilization management, including prior authorization, used by the MA plan." This means any UM policy being used, even if it is developed by a 3rd party (including InterQual).
Thank you,
CMS Part C Policy
As noted in the CY 2025 Medicare Advantage and Part D Final Rule (CMS-4205-F), Section E, Annual Health Equity Analysis of Utilization Management Policies and Procedures, the UM committee must conduct an annual health equity analysis of the use of prior authorization, and the member of the UM committee, who has health equity expertise, must approve the final report of the analysis before it is posted on the plan's publicly available website.
1. Is the expectation that the health equity analysis includes only medical necessity clinical criteria decisions? Or is the expectation to also include administrative decisions based on plan language - such as the beneficiary was not enrolled at the time of service, or the service is not covered out of the service area unless it is urgent, emergent or renal dialysis?
Hello Shelley,
The report must include all prior authorization requests.
Thank you,
CMS Part C Policy
I just want to confirm that dually eligible beneficiaries and LIS beneficiaries can enroll in any MA-PD they select only during the annual coordinated election period (AEP).
Is this correct?
Here's a little more on the SEP changes and then I'll answer your specific questions as well. The changes to the dual/LIS SEP at 42 CFR § 423.38(c)(4)(i) will allow dually eligible and other LIS-enrolled individuals to enroll once per month into any standalone prescription drug plan and Medicare fee-for-service, however, it will no longer permit enrollment into MA-PD plans or changes between MA-PD plans. Dually eligible and other LIS-eligible individuals would be able to enroll into MA-PD plans during the AEP, MA OEP or where another SEP permits. There is an additional SEP at 42 CFR § 423.38(c)(35) - the integrated care SEP - that allows full-benefit dually eligible individuals to enroll monthly into an integrated D-SNP (FIDE SNP, HIDE SNP, or AIP). This SEP can only be used to facilitate aligned enrollment between the integrated D-SNP and an affiliated Medicaid MCO.
In response to your example, if someone moved to another service area, they would have the SEP at 42 CFR § 423.38(c)(7) that allows them to make an enrollment change into any type of plan after relocating outside of the service area.
Let me know if you have any other questions.
Thanks,
CMS
Testimonials
What Our Clients Say About SME
Cindy Lynch
SVP, Chief Compliance & Privacy Officer
Alignment Health
I have known and worked with Shelley Segal for over 20 years. Shelley and her team are true experts and a pleasure to work with. Shelley has conducted Alignment's annual Medicare "Compliance Program Effectiveness" audit for a number of years.
I have found them to be very professional and collaborative, helping us to understand how we can continuously improve our Compliance Program. Shelley and her team also assisted us in preparing for a CMS Program audit and the support was invaluable.
Having Shelley's partnership, resources and subject matter experts on hand throughout the process definitely helped us with the heavy lifting associated with these audits.
Constance J. Snyder
Executive Vice President/Chief Compliance Officer
Champion Health Plans-USA
Champion Health Plan of California, Inc.
Renal Payer Solutions, Inc.
Champion Payer Solutions, LLC.
At my previous employer Brand New Day Health Plan, I used the assistance and auditing experience of Shelley and her team for over 10 years.
The Plan selected them year after year to help with audits and projects because the SME team are experts who are timely, professional, flexible, and very helpful in preparing for CMS audits.
We liked that they enabled us to learn to meet CMS standards and protocol by helping us to identify where adjustments were needed.
SME not only pointed out our weaknesses, but provided us with advice regarding steps we could take to meet our goal of 100% compliance.
A big "plus" is that Segal Medicare Experts responds quickly with citations and clarifications, and we could always count on them!
Michael Myers
CEO
Universal Healthcare MSO, LLC., DBA Sunrise Wellness Care
I have known Shelley for the past 30+ years, beginning when she was part of my operations and executive team.
With her knowledge and expertise in both the regulatory and health plan perspectives, Shelley provides her clients with effective and thoughtful solutions to some of the most complex Medicare Advantage issues facing the industry.
I have engaged Shelley and her team on many projects, and my staff greatly appreciate their insights, actionable recommendations and rolling up their sleeves to make things happen I look forward to continuing to work with Segal Medicare Experts in the future! They are really the subject matter experts.
Ryan C. Dodson, CRC
SVP, Chief Compliance & Privacy Officer
Chief Operating Officer/Co-Founder
Working with Shelley and her team at SME is an amazing experience.
I was starting a new company from scratch and Shelley took the time to help me set up an in-depth compliance program for me and my entire team.
She walked me through the entire process, and made sure that I understood what each document was and why it was important.
She kept me in the loop from the beginning of the process until the very end.
She made it easy for me!
Stephanie Schwartz, JD
Vice President, Government Relations
UCare
Now that this engagement has ended, Margaret and I wanted to thank you. It's always a pleasure learning from you and your staff, and we appreciated the support.
Thanks again - until next time!
Michael Blea
Chief Growth Officer
SCAN Health Plan
I have known Shelley for over 25 years.
During this time, I have often looked to her for guidance and could always count on getting the right answers about CMS regulations.
Her experience in sales offers suggestions to be compliant and successful.
This has been essential especially now when there is so much information and interpretation about CMS's intent about marketing to Medicare beneficiaries.
Shelley is a professional, ethical, and always timely with her response.