Disputes & Investigations

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Payer Disputes, Compliance and Investigations


As the managed care and healthcare landscape continues to evolve, one thing that remains constant is the continual change.  Increased government scrutiny and regulatory requirements, market consolidation and cost pressures converge to create an environment full of both opportunity and risk.

Navigant's Disputes, Compliance, and Investigations Payer practice has broad and deep expertise with all of these market forces in order to guide your organization toward achieving its strategic goals.  Our experts have worked with all types of payer entities including commercial, government (Medicare Advantage and Part D, Medicaid, Affordable Care Act), third-party administrators and pharmacy benefit managers, helping companies and their counsel. Our team includes former Government Programs Compliance Officers, Internal Audit Leaders, payer and PBM operations professionals, reimbursement specialists, clinicians, coders, accountants and statisticians.  

Compliance



  • Disputes, Compliance & Investigations Services for Healthcare Payers

  • Medicare Advantage & Medicare Part D - "Mock" Compliance Program Effectiveness and Program Audit Services

 

Operations and Payment

  • Operational Process Improvement in all areas including: Formulary and Benefit Administration, Coverage and Organizational Determinations, Appeals and Grievances, Special Needs Plans Models of Care, enrollment, provider networks, sales and marketing, and claims processing
  • Pharmacy Benefit Management vendor selection and audits
  • Risk Adjustment process reviews, data validation and program design/implementation
  • Medical Loss Ratio accounting and audit/investigation support

Disputes and Investigations

  • Consulting and Expert Witness Services
  • Class Certification Defense
  • Out-of-Network/UCR Disputes
  • Payment Disputes, including Risk Adjustment models
  • Federal and State Investigations
  • False Claims and Qui Tam Matters
  • Post-Acquisition Purchase Price Disputes
  • Narrow Network Disputes



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