Medicare ODAG Assessment Case Study

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Challenge

Although the payer had been in the Medicare industry for a long time, the team identified several compliance risks that required immediate mitigation and corrective actions. The payer understood not addressing these risks could result in audit findings, possible sanctions, or worse.

Results

The team presented the client with a final ODAG Assessment Report that identified compliance issues, turnaround time challenges, and Medicare operational process recommendations. The client liked the results so much, they immediately requested them to assist with implementing the recommendations. Work is currently underway on implementing the consultant’s recommendations.

The Firm

With team members averaging 15+ years of experience in the healthcare industry, our consultants have worked in a variety of management and I.T. leadership positions within commercial and government payer organizations, so we understand first-hand your challenges—including competitive pressures, organizational obstacles, and limited resources. Our experience includes assisting 100+ health plans in 47 states on diverse projects that range from complex, multi-year enterprise implementations to concise, efficient assessments or market inquiries.

Use-Case

A large, Southeast payer with multiple lines-of-business partnered with Change Healthcare Consulting to lead a Medicare Part C ODAG (Organization Determinations, Appeals and Grievances) Assessment. As part of the assessment, we made short- and long-term recommendations based upon their findings. Recommendations included: how to increase operating margins, improve operational processes, and ensure all Medicare compliance regulations are being followed. In a short five-month timeline, the client wanted quick-to-implement and realistic recommendations.

Solutions

The consulting team requested and reviewed the client's policies, procedures, workflows, utilization management and additional documentation. Although a range of issues were identified, the root cause of many of the non-compliance findings was an over-reliance on commercial policies and procedures rather than the required Medicare regulations. Change Healthcare Consulting also provided several recommendations to improve profitability and to reduce hospital readmissions. These recommendations will increase the client's profitability and improve their customer experience.

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