Compliance and investigations

We assist clients with Federal and State regulatory requirements, as well as key phases of an investigation.

Allegation Evaluation

Investigation Assistance

ACA Compliance Matters

Settlement Assistance

Mock Audits and Reviews

False Claims Act Investigation

Federal Procurement Regulations (such as FAR, CAS, FSS, and GSA)

Medicare Secondary Payer and Section 111

  • Reviewed encounter submission and reporting process related to numerous state Medicaid contracts, which included program management surrounding short-term encounter issue remediation and long-term system enhancement initiatives in response to state and federal investigations

  • Provided settlement support to various pharmaceutical manufacturers in federal, state, and class action matters associated with pricing and reimbursement, including extensive analysis of manufacturer, wholesaler, pharmacy benefit manager, and provider and health insurance data involved in the distribution and reimbursement of pharmaceutical drugs

  • Assisted clients in meeting the Section 111 Medicare Secondary Payer reporting requirements; performed onsite reviews of current data capture and reporting processes, and in some cases, prepared the quarterly submission files on behalf of health plans

Client Need

Client requested HealthScape’s assistance to identify the root cause for mistaken MSP underpayments made by the plan to CMS, quantify total damages, and develop disclosure support to CMS.

HealthScape Approach

  • Analyzed historical claims data to determine commonalities among the mistakenly paid claims in order to identify the root cause within the client’s processing system
  • Quantified all mistaken claims and prepared audit support for each impacted member
  • Worked with the client to voluntarily disclose the issue to CMS and advised them throughout the process

Outcomes

  • Identified the root cause for mistaken payments, which allowed the client to resolve the issue and prevent future damages
  • Corrected Section 111 reporting for impacted members
  • Disclosed and resolved issue with CMS
Service descriptions
Representative experience
Case study