Healthcare

Payer Services

The Ankura payer team brings a combination of compliance, operations, audit, clinical coding, data analytics, financial, valuation, and systems professionals to support payer executives and their counsel with regulatory compliance, operations, disputes, investigations, and transaction support and due diligence.

We have worked with all types of payer entities including commercial, government (Medicare Advantage and Part D, Medicaid, Affordable Care Act), third-party administrators, medical services organizations, and pharmacy benefit managers and have been deeply involved with all major and high-profile issues facing these payers over the past few decades.

List of Solutions

  • Compliance and Audit
    • Compliance program effectiveness review and compliance program organizational design
    • Annual risk assessments
    • Policy and procedure development
    • Medicare Advantage and Part D “mock” CMS compliance program effectiveness and program audits
    • Medicare Advantage and Part D CMS audit remediation and corrective action plan (CAP) development
    • Medicare Advantage and Part D independent validation auditors (IVA) and sanctions validations
    • Risk adjustment data validation (RADV) audits
    • Delegation oversight program implementation and ongoing support to oversee first tier, downstream, and related entities (FDRs)
    • Fraud, waste, and abuse (FWA) program development and implementation
    • Compliance due diligence of acquisition targets
    • Independent review organization (IRO) Services
  • Disputes and Forensics
    • Consulting and expert witness services
    • Class certification defense
    • Out-of-network/UCR disputes
    • Payment disputes, including risk adjustment payment models
    • Federal and state investigations
    • False claims act and qui tam matters
    • Post-acquisition purchase price disputes
    • Narrow network disputes
    • Medical, pharmacy and behavioral health payment and coverage disputes
    • Coverage disputes, including medical necessity and length of stay
  • Operations and Systems
    • Operations remediation for all core health plan areas
    • Corrective action plan (CAP) design and implementation
    • Operational process redesign and improvement
    • Pharmacy benefit management (PBM) vendor selection and audits
    • Operations due diligence
    • Risk adjustment end-to-end process reviews, clinical coding assessments, and program design/implementation
  • Valuation and Transaction Advisory
    • Fair market valuation opinions
    • Attorney General review applications
    • Not-for-profit conversions
    • Transaction fraud and abuse compliance
    • Value based incentive arrangements
    • Pricing analyses
    • Fairness opinions
    • Financial modeling and pro forma analyses
    • Buy-side and sell-side advisory
    • Financial reporting
    • Risk based capital forecasting
    • Expert witness testimony