CONTACT US: SME@SMEteam.org 562.334.7980

Segal Medicare Experts

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

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

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

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.

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.

 

Contact Us

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Our experts are standing by to help.
Call us or write to us today. Office: 562.334.7980

Email: SME@SMEteam.org

SEGAL MEDICARE EXPERTS


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