Medicare

Medicare represents the largest single source of Third Party Liability savings for state Medicaid programs. With our expertise in federal eligibility policies and procedures and understanding of the federal data sets available to states, we profile Medicaid populations and identify individuals who appear to qualify for additional Medicare benefits. This work has produced millions, in some cases billions, of dollars in cost avoidance for several state clients.

We have also been on the forefront of sweeping changes to Medicare as it relates to Medicare plan performance. For example, under the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) established new standards for Medicare plans that emphasize customer satisfaction, medication adherence and member health access and outcomes. Medicare plans are now given a Star Rating based on these measures that can affect their enrollment, ability to provide coverage, and potentially bonus payments. Immediately as these changes were implemented, we started working with plans to provide member and prescriber outreach and medication management services to enhance performance and influence Star Ratings.

Additional examples of our work and results include the following:

  • In 2009, we found errors that led to corrections in federal billing systems and returned a total of $250 million to all 50 states for improperly charged premiums. Since 2008, we have helped three states save and recover more than $120 million in Medicare premium overpayments.
  • By identifying Medicare coverage for Medicaid recipients and ensuring proper coordination of benefits, we are able to help the Commonwealth of Massachusetts avoid more than $2 billion in annual expenditures. 
  • We have experience managing Medicare appeals for states, skilled nursing facility services, and commercial insurers. We worked on appeals that resulted in more than $1 billion returned to New York Medicaid and $42 million returned to Massachusetts.
  • Since 2001, we have managed all operations of the Massachusetts Prescription Advantage Program, which went on to lead its national state pharmacy assistance program counterparts in a number of areas.
  • Through Medicare Part D billing services in one large state, we have been able to claim more than $20 million annually in Part D revenue on behalf of long-term care pharmacies.
  • Our high comprehensive medication review (CMR) completion rate helped one client achieve a 4-star rating for the medication therapy management star measure.