CONTACT US: SME@SMEteam.org | 562.334.7980
OUR SERVICES
The SME model provides solutions with less overhead than traditionally structured firms, so our services are efficient and economical. Our team delivers results by using their strong attention to details, solid decision-making skills, and the ability to work as both a leader and a member in a strong team environment. SME delivers custom-tailored solutions under one roof to help our clients save time and effort each time they are presented with a unique MA or Part D challenge.
At Segal Medicare Experts, we don’t offer “off-the-shelf” services. We meticulously craft solutions for every client through deep evaluation, thought leadership, and efficient application of industry best practices. We are a catalyst for creative action and a value-added integrator of service. Our virtual model enables us to assemble the best people at the right time.
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
- 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 Medicare Advantage and Part D Answers
- 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)
- Interviews for New Employees
- MA-PD/Part D Applications
- New Plan Implementation
- Process Re-engineering
- Provider Contracts
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
- Plan Website Creation
- Strategy
Training
- Medicare Advantage Functional Area Training through UL Pure Learning
- MA/Part D Computer Based and Live Training
- Side By Side 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 to move ahead. Let us help you 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 training
Compliant Marketing Solutions
Let Segal Medicare Experts ease the stress of your MAO, PDP and FMO by developing or reviewing your marketing materials. We can ensure compliance with the MCMGs, and train the team on the best resources. FMOs, we can also provide an interim Compliance Officer to implement and guide the day-to-day operations of your compliance program.
FMOs
- One-stop shop for asking all questions and interpretation of CMS regulations and guidance
- Complete Carrier 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 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
MAOs
- 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
Having a difficult time getting started with your CPE Audit?
Let Segal Medicare Experts help you to surpass any obstacles.
Contact Us
Our experts are standing by to help.
Call us or write to us today. Office: 562.334.7980
Email: SME@SMEteam.org
