The SME Report
Segal Medicare Experts (SME) – Industry News and Updates
Written by Shelley Segal and a team of Medicare Advantage Subject Matter Experts
Here’s what you need to know
Are you a small to medium Medicare Advantage health plan struggling to identify fraud, waste or abuse (FWA) leads? Want help identifying patterns in your claims data to facilitate regular recoveries from false billings?
The Centers for Medicare & Medicaid Services (CMS) released the 2022 Readiness Checklist with expectations for full compliance in 15 major areas “prior to the 2021 Annual Election Period (AEP) and coverage beginning January 1, 2022.”
CMS Requires Policies & Procedures and Implementation — “A Must”
CMS may at any time request policies and procedures and evidence of
Score High with Polished Policies - Win the Favor of CMS Auditors Is your Medicare Advantage health plan still in the early-to-mid stages of building a Special Investigations Unit (SIU)? Are you struggling to write program policies and procedures (P&Ps), or do you...
Within the context of health care, identity theft may be defined as an incident in which a beneficiary’s personal identity and/or insurance information has been (unlawfully) obtained (by an unauthorized individual) and is used for fraudulent or criminal activity.
WHAT OUR CLIENTS SAY ABOUT SME
“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!”
“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.”
“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!”
“Shelley and her team are meticulous and well-versed in the Medicare Managed Care industry. I can count on her for timely and accurate results to help navigate complex issues in a variety of areas. She is always there when needed and goes above and beyond to deliver exceptional support and results.”
Having a difficult time getting started with your CPE Audit?
Let Segal Medicare Experts help you to surpass any obstacles.
SME has a comprehensive team of CMS Program Audit experts, including SME leaders who previously worked at CMS and have first-hand experience conducting CMS Program Audits.
Additionally, SME respects and appreciates how important it is for MAOs, PDPs, and MMPs to be front and center with CMS, leading their performance during a Program Audit. This is why SME uses a behind-the-scenes approach, which provides you with full audit support, including:
✓ Clarification of audit requirements throughout the audit process
✓ Review of documentation, including data universes, prior to submission, during fieldwork, and if needed, throughout validation and close out
✓ Training associates and FDRs on strong audit performance skills
✓ Best practices in conducting and leading tracer reviews
✓ Assistance with technology and facility set up to ensure a smooth audit experience, including connectivity with your FDRs
✓ Taking notes and tracking deliverables throughout fieldwork
✓ Guidance for and review of any corrective action required as a result of the audit
✓ Drafting communications to keep FDRs, leadership, employees, and key stakeholders informed of the audit process and outcomes.
Regardless of your current state of audit readiness, adding Segal Medicare Experts to your CMS Program Audit team provides your organization and associates with additional assurance by an expert professional team to conduct your annual CPE audit.
SME will help you prepare documents in advance, to avoid that last-minute scramble after you receive a CMS audit notice.
Our experts are standing by to help.
Call us or write to us today. Office: 562.334.7980