Our vast health plan experience is derived from working with nearly a hundred different health plans, ranging from small, local market health plans to large, multi-state health plans… from health plans with 1,000 lives and one line of business to those with over a million lives in multiple lines of business, including commercial, exchanges, Medicare and Medicaid plans. We understand the real challenges facing pharmacy directors, operational areas, actuaries and compliance officers today, and we have the solutions to help.
Our seasoned audit and compliance team has the expertise and experience to support health plans through all of their oversight needs. We conduct over one hundred audits each year on behalf of health plans to verify that our clients’ operations and client’s vendors (including their PBMs) operate in compliance with contract terms and appropriate CMS regulations. Our team works closely with health plans to develop a customized audit and oversight plan to minimize risk and give health plan compliance teams confidence that they are covered. Our engagements are closely tailored to your needs, whether detailed medical utilization reviews, writing technical source code for your CMS reporting, or analyzing vast amounts of information – our experts have seen it all and we’ve built the tools to handle it.
We understand the intricacies of a PBM procurement project within a health plan and are experienced working with the stakeholders including, operations, compliance, actuarial, legal, sourcing, and pharmacy. We work with virtually every PBM in the market, keeping us on the forefront of contracting methodologies, pricing strategies, rebate options and plan management innovations. Our volume of work provides a valuable knowledge base to provide key recommendations of PBM contracting strengths and weaknesses.
Our health plan experience expands beyond procurement and audit & compliance. Our consultants understand the operational challenges facing health plans today. We help our health plan clients implement best practices, control costs, predict and manage specialty pharmacy spend, and improve operational efficiency.