Implementation and Compliance Aspects of a Medicare ... · 2/9/2015 1 Presented To: Implementation...

2/9/2015

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Presented To:

Implementation and Compliance Aspects of a

Medicare-Medicaid Program

February 16, 2015 HCCA Managed Care Conference

Table of ContentsTable of ContentsTable of ContentsTable of Contents

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I. Medicare-Medicaid Program (MMP) | Introduction and Background 3

II. Process for Implementation of a MMP Program 8

III. Preparing for Implementation

a. Enrollment Systems

b. Utilization Management

c. Care Coordination

d. Enrollee and Provider Communication

e. Provider Network and Credentialing

f. Enrollee Protections and Rights

g. Organizational Structure and Staffing

h. Claims Processing and Payment

i. Pharmacy Claims Processing

j. Compliance Program Administration

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IV. NORC Audit | Onsite Readiness 39

V. Q&A Session 45

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MedicareMedicareMedicareMedicare----Medicaid Program (MMP) | Medicaid Program (MMP) | Medicaid Program (MMP) | Medicaid Program (MMP) |

Introduction and BackgroundIntroduction and BackgroundIntroduction and BackgroundIntroduction and Background

Medicare Medicare Medicare Medicare –––– Medicaid Program (MMP) | Medicaid Program (MMP) | Medicaid Program (MMP) | Medicaid Program (MMP) |

Introduction and BackgroundIntroduction and BackgroundIntroduction and BackgroundIntroduction and Background

The Federal Coordinated Health Care Office serves people who are enrolled in both the Medicare and Medicaid programs. These enrollees are know as dual eligibles.

The Medicare-Medicaid Coordination Office was established under the Affordable Care Act and serves dual eligibles. Its goal is to ensure enrollees have access to seamless, high quality health care, and to make the system cost effective.

The programs and benefit plans established that serve dual eligibles have evolved in recent years with the advent of demonstration programs overseen by CMS. These programs are often termed Medicare-Medicaid Programs (MMPs)

The overall goal of an MMP is to improve the quality of care and long-term services for dual eligible individuals through enhanced continuity of care and effective care transitions.

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Demonstration DesignDemonstration DesignDemonstration DesignDemonstration Design

Health plans that receive approval to participate in the MMP Demonstration enter

into a three-way contract between CMS and the State to provide coverage for the

dual eligible population.

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•Health plans must follow the specific Medicare elements of the MMP initiative and operate according to the existing Medicare Advantage (Part C) and Medicare Prescription Drug Program (Part D) laws and regulations.

MedicareMedicareMedicareMedicare

•Health plans must also operate according to the state-specific Medicaid laws and regulations. This includes adherence to the Medicaid Managed Care requirements under Title XIX of the Social Security Act and 42 C.F.R. § 438 et. seq.

MedicaidMedicaidMedicaidMedicaid


Delivery Systems and Benefits OverviewDelivery Systems and Benefits OverviewDelivery Systems and Benefits OverviewDelivery Systems and Benefits Overview

CMS and the State will contract with plans that demonstrate the capacity to

provide, directly or by subcontracting with other qualified entities, the full

continuum of Medicare and Medicaid covered services to enrollees in

accordance to the MMP Memorandum of Understanding, CMS guidance,

and the three-way contract.

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CMS CMS CMS CMS and the State may choose to allow greater and the State may choose to allow greater and the State may choose to allow greater and the State may choose to allow greater

flexibility in offering additional benefits that exceed flexibility in offering additional benefits that exceed flexibility in offering additional benefits that exceed flexibility in offering additional benefits that exceed

those benefits currently covered by either Medicare those benefits currently covered by either Medicare those benefits currently covered by either Medicare those benefits currently covered by either Medicare

or Medicaid.or Medicaid.or Medicaid.or Medicaid.

Benefit StructureBenefit StructureBenefit StructureBenefit Structure

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Key ObjectivesKey ObjectivesKey ObjectivesKey Objectives

•Provide seamless access to support and services for Medicare-Medicaid enrollees

•Create a person-centered model to coordinate support and services that communicate with and link back to all domains of the delivery system

•Streamline administrative processes for the Medicare-Medicaid enrollees and providers

•Eliminate barriers to and encourage the use of home and community-based services

•Provide quality services that also focus on enrollee satisfaction

•Demonstrate cost effectiveness for the state and federal government through improved care coordination, financial realignment, promotion of best practices, and payment reform

•Improve the quality of care for members

•Promote member independence in the community

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Process for Implementation of a MMP ProgramProcess for Implementation of a MMP ProgramProcess for Implementation of a MMP ProgramProcess for Implementation of a MMP Program

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Implementing a MMP Implementing a MMP Implementing a MMP Implementing a MMP Program Program Program Program | | | | Overview Overview Overview Overview

File a Demonstration Plan application with CMS. The application must demonstrate to CMS and the State that the organization possesses the ability to provide medical and prescription drug benefits to eligible beneficiaries.

If approved, CMS will contact the plan through its contractor, NORC, at the University of Chicago, to request policies and procedures that apply to the Demonstration.

NORC will evaluate the submitted documentation against specific Readiness Review criteria in a desk review.

NORC will provide a report of any deficiencies identified and will provide the plan an opportunity to make corrections.

NORC will coordinate with the plan to conduct an onsite audit, which will consist of interviews, system demonstrations, and scenario testing.

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Implementing a MMP Program | Implementing a MMP Program | Implementing a MMP Program | Implementing a MMP Program | NORC Areas of ReviewNORC Areas of ReviewNORC Areas of ReviewNORC Areas of Review

Enrollment Processing and Health Risk Assessment

Utilization Management

Enrollee and Provider

Communications

Provider Network and

Credentialing

Organization Structure and

Staffing

Compliance Program

Administration

Claims Processing and

Payment

Pharmacy Claims

Processing and Payment

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Preparing for Preparing for Preparing for Preparing for Implementation Implementation Implementation Implementation | | | | Enrollment Enrollment Enrollment Enrollment Systems Systems Systems Systems

Enrollment Systems Implementation| Enrollment Systems Implementation| Enrollment Systems Implementation| Enrollment Systems Implementation| OverviewOverviewOverviewOverview

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Each Each Each Each State is responsible for the enrollment process State is responsible for the enrollment process State is responsible for the enrollment process State is responsible for the enrollment process criteria.criteria.criteria.criteria.

� The state enrollment broker is responsible for providing the enrollment file to the health plan.

� In very limited instances, CMS may delegate specific functions to the MMPs but not delegate

passive enrollment, collecting health-related information during voluntary enrollment, or

involuntary disenrollment.

� States send enrollment related notification to CMS’ MARx enrollment vendor.

� States attempt to assign beneficiaries to an MMP that best fits their needs.

Passive EnrollmentPassive EnrollmentPassive EnrollmentPassive Enrollment Voluntary EnrollmentVoluntary EnrollmentVoluntary EnrollmentVoluntary Enrollment

� Beneficiaries have Medicare Part

A and Part B

� Beneficiaries have full Medicaid

eligibility

� Beneficiaries reside permanently

within the MMP service area

� Beneficiaries choose to enroll in a

specific MMP

� Members can also “Opt Out”

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Enrollment Systems Enrollment Systems Enrollment Systems Enrollment Systems Implementation | Implementation | Implementation | Implementation | Overview Cont’d.Overview Cont’d.Overview Cont’d.Overview Cont’d.

The MMP must establish an enrollment system that is fully capable to receive,

process, and reconcile information accurately and timely.

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Data Elements:Data Elements:Data Elements:Data Elements:

� Name

� Date of birth

� Gender

� Telephone number

� Permanent residence address

� Mailing address

� Medicare and Medicaid numbers

� ESRD status

� Other insurance COB information

� Language and alternative formats preferences

� Authorized representative contact information

� The plan the individual is currently enrolled in and the MMP into which the individual desires to enroll

MMP Enrollment SystemMMP Enrollment SystemMMP Enrollment SystemMMP Enrollment System

Enrollment Systems Enrollment Systems Enrollment Systems Enrollment Systems Implementation | Implementation | Implementation | Implementation | Overview Cont’d. Overview Cont’d. Overview Cont’d. Overview Cont’d.

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For For For For voluntary enrollmentsvoluntary enrollmentsvoluntary enrollmentsvoluntary enrollments, the MMP must send the following to , the MMP must send the following to , the MMP must send the following to , the MMP must send the following to

the the the the enrollee enrollee enrollee enrollee 30 days 30 days 30 days 30 days prior prior prior prior to the effective date of coverage:to the effective date of coverage:to the effective date of coverage:to the effective date of coverage:

� A comprehensive, integrated formulary that includes Medicare

and Medicaid outpatient prescription drugs and pharmacy

products provided by the MMP

� A combined provider and pharmacy directory that includes all

providers of Medicare, Medicaid, and additional benefits

For For For For passive enrollmentspassive enrollmentspassive enrollmentspassive enrollments, the MMP must send the following to the e, the MMP must send the following to the e, the MMP must send the following to the e, the MMP must send the following to the enrollee nrollee nrollee nrollee

no later than the last calendar day of the month prior to the effective date no later than the last calendar day of the month prior to the effective date no later than the last calendar day of the month prior to the effective date no later than the last calendar day of the month prior to the effective date

of coverage:of coverage:of coverage:of coverage:

� A single plan ID card for accessing all covered services under the MMP; and

� A Member Handbook (Evidence of Coverage).

� Proof of health insurance coverage, including the 4Rx prescription drug data necessary to

access benefits so the enrollee may begin using services on the enrollment effective date of.

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Preparing for Implementation Preparing for Implementation Preparing for Implementation Preparing for Implementation | | | | Utilization Utilization Utilization Utilization Management Management Management Management

Utilization Management Utilization Management Utilization Management Utilization Management Implementation | Implementation | Implementation | Implementation | OverviewOverviewOverviewOverview

MMPs must have an established Utilization Management (UM) program to

process requests for initial and continuing authorizations of covered services.

UM Program RequirementsUM Program RequirementsUM Program RequirementsUM Program Requirements

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Defined protocols for authorizing out-of-network services1111

Documented and specific procedures under which the Enrollee may self-refer services

2222

Defined review criteria, information sources, and processes used to review and approve the provision of services and prescription drugs

3333

Established methodology for periodically reviewing and amending the UM review criteria, including criteria for prescription drug coverage

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Policies, procedures, and systems to detect both under- and over-utilization of services and prescription drugs

5555

Defined processes for communicating to providers the specific services that require prior authorization and the corresponding

procedures and timeframes6666

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Preparing for Preparing for Preparing for Preparing for Implementation Implementation Implementation Implementation | | | | Care Coordination Care Coordination Care Coordination Care Coordination

Care Coordinator ResponsibilitiesCare Coordinator ResponsibilitiesCare Coordinator ResponsibilitiesCare Coordinator Responsibilities

UM Program RequirementsUM Program RequirementsUM Program RequirementsUM Program Requirements

Supporting an ongoing person-centered planning process

Conducting a risk assessment for each enrollee, including a clinical risk and needs assessment

Facilitating timely access to primary care, specialty care (e.g. behavioral health services), medications, and any other necessary health services

Coordinating referrals to address any physical or cognitive barriers

Facilitating communication amongst the member’s providers and Care Coordination Team

Facilitating any activities or services deemed necessary to assist the member in optimizing his or her health status

Care Coordination Care Coordination Care Coordination Care Coordination Implementation | Implementation | Implementation | Implementation | OverviewOverviewOverviewOverview

MMP plans must have an established Care Coordination process for each enrollee

with dedicated staff.

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Care Coordination Implementation Care Coordination Implementation Care Coordination Implementation Care Coordination Implementation | | | | Risk AssessmentRisk AssessmentRisk AssessmentRisk Assessment

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All MMP enrollees will receive a comprehensive health risk assessment that must

be completed within 90 days of the individual’s enrollment date.

What is included in the assessment?What is included in the assessment?What is included in the assessment?What is included in the assessment?

Input from caregivers

Enrollee preferences

Enrollee data

Wellness and prevention

strengths and goals

Wellness and prevention domains

Functional status

Social needsPhysical and behavioral health

Care Coordination Implementation | Care Coordination Implementation | Care Coordination Implementation | Care Coordination Implementation | NORC ScenariosNORC ScenariosNORC ScenariosNORC Scenarios

The NORC auditors will request the MMP to walk through a scenario to

demonstrate a comprehensive understanding of the care coordination

Demonstration requirements.

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Preparing for Preparing for Preparing for Preparing for Implementation Implementation Implementation Implementation | | | | Enrollee and Provider Communication Enrollee and Provider Communication Enrollee and Provider Communication Enrollee and Provider Communication

Enrollee and Provider Communication Implementation Enrollee and Provider Communication Implementation Enrollee and Provider Communication Implementation Enrollee and Provider Communication Implementation ||||Customer ServiceCustomer ServiceCustomer ServiceCustomer Service

Each MMP plan must implement specific processes for Each MMP plan must implement specific processes for Each MMP plan must implement specific processes for Each MMP plan must implement specific processes for

communicating with enrollees and their providers, communicating with enrollees and their providers, communicating with enrollees and their providers, communicating with enrollees and their providers,

including: including: including: including:

� Toll-free enrollee service telephone line center that

operates from 8:00 A.M. - 8:00 P.M. seven days a week

with a “live” representative

� After-hours hotline available to providers 24/7 in order

to request prior authorizations and discharge planning

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The staff communicating to enrollees and providers must be appropriately trained The staff communicating to enrollees and providers must be appropriately trained The staff communicating to enrollees and providers must be appropriately trained The staff communicating to enrollees and providers must be appropriately trained

and qualified health professionals. They must be trained to: and qualified health professionals. They must be trained to: and qualified health professionals. They must be trained to: and qualified health professionals. They must be trained to:

� Answer care coordination questions, assess the enrollee’s issues, and provide an

appropriate course of action

� Use TTY, interpretation services, and other alternative communication formats

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Preparing for Preparing for Preparing for Preparing for Implementation Implementation Implementation Implementation | | | | Provider Network and Credentialing Provider Network and Credentialing Provider Network and Credentialing Provider Network and Credentialing

Provider Network and Credentialing Provider Network and Credentialing Provider Network and Credentialing Provider Network and Credentialing Implementation | Implementation | Implementation | Implementation |

OverviewOverviewOverviewOverview

The MMP must have a clear plan to meet the Medicare and Medicaid provider The MMP must have a clear plan to meet the Medicare and Medicaid provider The MMP must have a clear plan to meet the Medicare and Medicaid provider The MMP must have a clear plan to meet the Medicare and Medicaid provider

network standards. network standards. network standards. network standards. The plan must consider the following:The plan must consider the following:The plan must consider the following:The plan must consider the following:

� Anticipated enrollment

� Expected utilization of services, given the characteristics and health care needs of

the population

� Number and type of experienced and specialist providers required to furnish

services, including LTSS providers

� Whether or not providers are accepting new enrollees

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Additional Requirements: Additional Requirements: Additional Requirements: Additional Requirements:

The MMP policies and procedures must clearly describe the process for selecting a specialist as a

PCP.

The network must include providers whose physical locations and diagnostic equipment accommodate

individuals with disabilities.

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Preparing for Preparing for Preparing for Preparing for Implementation Implementation Implementation Implementation | | | | Enrollee Protections and Rights Enrollee Protections and Rights Enrollee Protections and Rights Enrollee Protections and Rights

Enrollee Protections and Rights Enrollee Protections and Rights Enrollee Protections and Rights Enrollee Protections and Rights Implementation | Implementation | Implementation | Implementation |


MMP Requirements for Enrollee Protections and Rights:MMP Requirements for Enrollee Protections and Rights:MMP Requirements for Enrollee Protections and Rights:MMP Requirements for Enrollee Protections and Rights:

� Enrollee rights and protections must be established and communicated to ensure

enrollees are free to exercise those rights without negative consequences.

� Policies must clearly articulate that enrollees will be notified of their rights and

protections at least annually and in a manner appropriate to their condition and

ability to understand.

Established policies Established policies Established policies Established policies and procedures and procedures and procedures and procedures and and and and robust training protocols robust training protocols robust training protocols robust training protocols must be in must be in must be in must be in

place to place to place to place to ensure ensure ensure ensure enrollees are not discriminated based on:enrollees are not discriminated based on:enrollees are not discriminated based on:enrollees are not discriminated based on:

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Medical condition

Claims experience

Receipt of health care

Medical history

Genetic information

Evidence of insurability

Disability Age

Sexual orientation

Religion

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Preparing for Preparing for Preparing for Preparing for Implementation Implementation Implementation Implementation | | | | Organizational Structure and Staffing Organizational Structure and Staffing Organizational Structure and Staffing Organizational Structure and Staffing

Elements of the Staffing PlanElements of the Staffing PlanElements of the Staffing PlanElements of the Staffing Plan

Organizational Structure and Staffing Organizational Structure and Staffing Organizational Structure and Staffing Organizational Structure and Staffing Implementation | Implementation | Implementation | Implementation |


The MMP’s staffing plans must demonstrate staffing ratios that are appropriate for

supporting the needs of each enrollee and addressing a large influx of membership through

passive enrollments.

NoteNoteNoteNote: The rationale for sufficient call

center operations staff must

address:

1) The general enrollee services

telephone line

2) The coverage determinations,

grievances, and appeals telephone

line

3) The call-in system (staffed 24/7)

4) The pharmacy technical help desk.

An estimate of enrollees during the enrollment period

Detailed description of staff positions

that will support all functions

Estimate of staff needed to perform

the functions

Methodology used to

determine the estimate of staff

Rationale for sufficient call center

operations staff

Timeframe for staffing to the

appropriate level

Indication whether contractors will be used to support the

functions

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Organizational Structure and Staffing Implementation| Organizational Structure and Staffing Implementation| Organizational Structure and Staffing Implementation| Organizational Structure and Staffing Implementation|

TrainingTrainingTrainingTraining

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The MMP trainings must be rolled out to each staff member who will be in

contact with an enrollee. In addition, specific training is required for Care

Coordinators.

General Staff TrainingGeneral Staff TrainingGeneral Staff TrainingGeneral Staff Training

•Cultural competency and disability to ensure each staff member delivers cultural-competent services in both verbal and written communications

•Handling critical incident and abuse reporting, including methods to detect and report instances of abuse, neglect, and exploitation

•HIPAA compliance obligations and confidentiality guidelines

Care Coordinator TrainingCare Coordinator TrainingCare Coordinator TrainingCare Coordinator Training

•Needs assessment and care planning

•Respect for cultural, spiritual, racial, and ethnic beliefs of others

•Assessing members’ medical, behavioral health, and social needs and concerns

•Self-direction of services (as authorized by the state)

•Care transitions

•Abuse and neglect reporting

•Community resources

•Identifying behavioral health and LTSS needs

Preparing for Preparing for Preparing for Preparing for Implementation Implementation Implementation Implementation | | | | Claims Processing and Payment Claims Processing and Payment Claims Processing and Payment Claims Processing and Payment

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Claims Processing and Payment Claims Processing and Payment Claims Processing and Payment Claims Processing and Payment Implementation | Implementation | Implementation | Implementation |

Overview and Key RequirementsOverview and Key RequirementsOverview and Key RequirementsOverview and Key Requirements

� The MMP is required to establish a system that appropriately processes accurate, timely, and HIPAA-compliant claims and adjustments. This includes established processes and timeframes for managing pending claims.

� The claims system must have the capacity to process the volume of claims anticipated under the Demonstration.

� The claims system must appropriately adjudicate claims for Medicare Part D, Medicaid prescription, and Medicaid over-the-counter drugs.

� The MMP must pay 95% of clean medical, behavioral, and LTSS claims within 30 days of receipt.

� The MMP, or its PBM, must pay clean claims from network pharmacies within 14 days of receipt for electronic claims.

� The MMP, or its PBM, establishes a process to ensure pharmacies located in, or having a contract with, a long-term facility do not have less than 30 days or more than 90 days to submit a claim for reimbursement.

� The MMP must establish a claims processing system check for erroneous payments.

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Claims Processing and Payment Claims Processing and Payment Claims Processing and Payment Claims Processing and Payment Implementation | Implementation | Implementation | Implementation |

NORC ScenariosNORC ScenariosNORC ScenariosNORC Scenarios


demonstrate a comprehensive understanding of the claims processing


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Preparing for Preparing for Preparing for Preparing for Implementation Implementation Implementation Implementation | | | | Pharmacy Claims Processing Pharmacy Claims Processing Pharmacy Claims Processing Pharmacy Claims Processing

Pharmacy Systems Pharmacy Systems Pharmacy Systems Pharmacy Systems Implementation | Implementation | Implementation | Implementation | OverviewOverviewOverviewOverview

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The MMP must establish protocols to oversee its PBM, including

conducting routine audits of the PBM’s pharmacy systems.

Claims Adjudication System Claims Adjudication System Claims Adjudication System Claims Adjudication System and Processes Oversightand Processes Oversightand Processes Oversightand Processes Oversight

Distinguishing between filling prescriptions for Part D drugs and

non-Part D drugs

Appropriately meeting the 90-day Part D and the non-Part D transition fill requirements

Ensuring that all prior approvals will be honored 90 days after enrollment and will not be

terminated without advance notice to the enrollee and a transition to other drugs or therapies, if needed

Other Areas of OversightOther Areas of OversightOther Areas of OversightOther Areas of Oversight

Maintaining and updating records on pharmacy network information,

including current providers, locations, and operating hours

Providing notifications to enrollees regarding pharmacies no longer

participating in the network

Properly coordinating benefits with secondary payers through

utilization of unique routing and enrollee identifiers

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Pharmacy Claims Processing Implementation Pharmacy Claims Processing Implementation Pharmacy Claims Processing Implementation Pharmacy Claims Processing Implementation | | | |

NORC ScenariosNORC ScenariosNORC ScenariosNORC Scenarios


demonstrate a comprehensive understanding of the pharmacy claims processing


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Preparing for Preparing for Preparing for Preparing for Implementation Implementation Implementation Implementation | | | | Compliance Program Administration Compliance Program Administration Compliance Program Administration Compliance Program Administration

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Compliance Program Administration Compliance Program Administration Compliance Program Administration Compliance Program Administration Implementation | Implementation | Implementation | Implementation |


The MMP program must be integrated into the plan’s existing compliance operations.

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Auditing and monitoring activities

Established policies and procedures

Compliance reporting during Compliance Committee meetings

Effective processes for responding to, investigating, and correcting compliance issues

Fraud, waste, and abuse trainings

Staff trainings on MMP compliance requirements

Processes for addressing and implementing regulatory changes

Oversight of first tier, downstream, and related entities (FDRs)

Well publicized disciplinary standards provided to FDRs

MMP ComplianceMMP ComplianceMMP ComplianceMMP Compliance

ProgramProgramProgramProgram

ComponentsComponentsComponentsComponents

NORC Audit NORC Audit NORC Audit NORC Audit | | | |

Onsite ReadinessOnsite ReadinessOnsite ReadinessOnsite Readiness

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NORC Audit | NORC Audit | NORC Audit | NORC Audit | Onsite Onsite Onsite Onsite Readiness TipsReadiness TipsReadiness TipsReadiness Tips

■ A “lead” staff person should be assigned to be a liaison for the NORC auditors and show

where designated areas are located, such as restrooms and the cafeteria.

■ Security ID badges for the regulators should be created prior to their arrival to eliminate

any delays in the start of the onsite audit.

■ Set up wireless access with passwords ahead of the auditors’ arrival in the event they

will need to access the internet or email systems.

■ In the event that conference call or Webinar capabilities will be utilized during the onsite

sessions, conference numbers and Webinar configurations should be tested prior to the

actual onsite audit date.

■ Communication should be provided to all staff involved in the onsite audit that Outlook

and Instant Messenger capabilities should be disabled from their computers while

presenting to auditors.

■ Ensure all relevant plan staff is present and on time for the audit sessions. There should

be one designated PC for presentation purposes during the NORC onsite.

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NORC Audit | NORC Audit | NORC Audit | NORC Audit | Onsite Readiness Onsite Readiness Onsite Readiness Onsite Readiness Tips Cont’d.Tips Cont’d.Tips Cont’d.Tips Cont’d.

■ In anticipation of requested documentation, all supporting documentation, such as

policies, procedures, and workflows should be maintained on the designated PC which

will be used during the course of the audit sessions.

■ There should be a designated speaker for each session during the audit who has full

knowledge of the MMP Program area and how it will be administered should be

assigned.

■ Arrangements should be made for full system access and clear system displays for

demonstration purposes. Further, knowledgeable staff should be made available that

can walk through relevant systems, including scenario testing walkthroughs.

■ The MMP should be prepared to provide and present a proposed organizational chart for

each audited program area, if requested by NORC.

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Q&AQ&AQ&AQ&A

FTI Consulting, Inc. FTI Consulting, Inc. FTI Consulting, Inc. FTI Consulting, Inc. | | | | Biographies Biographies Biographies Biographies

2/9/2015

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About

Richard Richard Richard Richard MerinoMerinoMerinoMerino

Managing Director

Charlotte, NC

+1 704 972 4156

[email protected]

Richard Merino is a Managing Director in the FTI Consulting

Health Solutions segment and is based in Charlotte. Mr. Merino

specializes in assisting legal counsel and ultimate clients with

regulatory compliance, health plan and healthcare entity

operations within the Managed Care, Healthcare Provider and

Pharmaceutical industries.

Mr. Merino’s experience includes the compliance, operational

and dispute resolution matters pervasive in the healthcare

industry from both a payer and provider perspective. Mr. Merino

has more than 10 years of experience in healthcare consulting

and Managed Care compliance and operations.

Mr. Merino has assisted many of the largest managed care

plans with all aspects of regulatory and contract compliance.

He has conducted numerous risk assessments and has

designed and implemented Medicare Advantage and Part D

(MA-PD) and Prescription Drug Program (PDP) compliance and

Fraud, Waste, and Abuse programs. Mr. Merino has advised

multiple managed care organizations of their risks related to

claims, enrollment, sales and marketing and reimbursement

operations.

Mr. Merino led a multi-million dollar investigation of a large

regional Medicare contractor accused by CMS and the

Department of Justice of claims processing irregularities. He

has also assisted many clients with governmental inquiries

including CMS, DOJ and OIG communications and negotiations.

Mr. Merino has led “mock” CMS audits of various Medicare

Advantage and Part D plan sponsors. He has also reviewed the

operational sufficiency of Medicare and Medicaid health plan

functions including: Enrollment/Disenrollment, Claims,

Marketing and Sales, Encounter Data, Quality Assurance, and

Utilization and Disease Management, Provider Contracts, and

Payment Reconciliation.

Mr. Merino has supported numerous clients in litigation and

arbitration related to disputes over managed care, payer-

provider and other healthcare matters for Medicare and

Commercial entities.

Mr. Merino was named expert in a litigation involving a dispute

between a health plan and third party administrator related to

the TPA’s performance of certain contracted and regulatory

duties related to a Medicare Private Fee For Service product.

Prior to joining FTI Consulting, Mr. Merino was a Director in the

Pharmaceuticals and Health Plans practice of Huron Consulting

Group and a Senior Managing Consultant in the Healthcare

Group of Navigant Consulting.

Professional Professional Professional Professional

AffiliationsAffiliationsAffiliationsAffiliations

Member, Health

Care Compliance

Association

EducationEducationEducationEducation

J.D, Mississippi

College School of

Law

43

About

Bethany Cochran

Senior Consultant

Charlotte, N.C.

+1 704.972.4133

[email protected]

Bethany Cochran is a senior consultant in FTI’s national Health

Solutions practice and is based in Charlotte. Ms. Cochran

specializes in regulatory compliance and performance

improvement serving clients in the managed care and

government contracted health plan markets related to

Medicare Advantage and Part D. Ms. Cochran has performed

operational reviews including mock CMS Program Audits of

health plans related to formulary administration, enrollment,

compliance program effectiveness, marketing and sales,

coverage determinations, organization determinations, appeals

and grievances, electronic health records and HIPAA and

HITECH. Bethany has performed and led Readiness Reviews of

several state health plans attempting to qualify for the

Medicare-Medicaid Financial Alignment Initiative. This included

performing policy reviews consistent with program

requirements and conducting mock NORC audits. Bethany has

performed and managed several operational reviews for a large

national health plan in order to improve compliance with CMS

requirements for prior authorization, appeals and grievances.

The work included identifying gaps in current processes and

designing and implementing future state operations. In

addition, Bethany has conducted several pre-attestation

meaningful use audits for a large national health plan related

to the Medicare Advantage Electronic Health Record Incentive

Program in order to identify providers eligible for incentive

payments. Bethany also performed a comprehensive HIPAA and

HITECH audit for a health plan undergoing a security breach

investigation by the OCR. Her work included evaluating existing

privacy and security policies and procedures, interviews,

security walkthroughs and providing best-practice

recommendations for strengthening the plan’s compliance with

HIPAA and HITECH.

Ms. Cochran earned a B.A. in Economics from the University of

North Carolina at Chapel Hill.

EducationEducationEducationEducation

B.A. Economics,

University of North

Carolina, Chapel Hill

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