government programs
& managed care

government programs & managed care

Government Programs & Managed Care

With more than 15 years of experience providing care for primarily Medicaid and Medicare patients from multiple states (namely WA, AL, AK, ID, OR, MT), we know firsthand the challenges and confusion the variation of these government programs can present to healthcare entities and affected patient populations. Deciphering the requirements for Medicaid programs versus Managed Care Organizations versus the Exchanges versus Medicare can be daunting, and even when a program finally starts to make sense you can rest assured major changes are on the way again. It’s the nature of the United States healthcare system. Let our lived, boots on the ground expertise be your guide to providing high quality, program-compliant care to these members. There is no operational or compliance-related challenge we cannot partner with you to help you solve. Our consultants keep their ear to the ground on upcoming regulatory changes that will impact clients and advocate on their behalf, share resources and helpful tools, and keep the clients apprised with regular touch points so that incorporating required changes are minimally disruptive to business operations and patient care.

We have successfully worked directly with Pharmacy Benefit Managers (PBMs) to renegotiate more favorable reimbursement rates for struggling pharmacies during contract renewal, and by maintaining strong collaborative relationships with many health plans, we have positively influenced formulary decisions that benefited patient outcomes as well as pharmacy revenues.

By proposing creative and data-driven solutions to broaden the plan’s preferred pharmacy network (for both retail and specialty) that save the PBM money, increase prescription throughput and revenues, and contribute to improved health benefits to members, we are proud to have been on the bleeding edge of the value-based healthcare movement. The value-based model is a much-needed departure from traditional fee-for-service payment structures that have led to the US healthcare system being more of a place for providing ineffective and expensive “sick care”. The value-based model is progressing as more big-name self-funded companies are examining ways to contain ballooning healthcare costs, particularly around medication management and caring for members living with complex chronic conditions. Given our breadth of experience working within both fee-for-service and value-based care models, we can act as a valuable resource to you no matter where you fall on the spectrum of pharmacy contracting that influences how care is provided within your business.

Whether you’re a start-up program or an existing program, our experts can guide you through the complex health plan and pharmacy benefits marketplace to validate your operational compliance while finding cost containment and revenue generating opportunities that keep members’ health top of mind. Let us help you gain peace of mind and put you on the right path – Contact us today.

Our specialized skills in Medicare Part D, Medicaid, and commercial plans will help your business prepare for Centers for Medicare and Medicaid Services (CMS), third party, and other regulatory agency audits. Our approach is simple: We will conduct an on-site mock audit of your operations, report out on risks and readiness, make recommendations for short-term remediation on any existing gaps, and help you design and implement long-term compliance strategies to future-proof your audit risks.

Additional ad-hoc services we offer:

  • Medicaid prescription drug benefit and formulary review

  • Generic utilization and state maximum allowable cost (MAC) evaluation

  • Maximizing HEDIS and CMS Star ratings for quality measures

  • Assist with/monitor Prescription Drug Event (PDE) audits

  • Medication Therapy Management (MTM) recommendations

  • Direct and Indirect Renumeration (DIR) reconciliation

  • Comprehensive PBM claims review and analysis for accuracy and cost savings opportunity