Risk, Regulatory & Compliance

Risk, Regulatory & Compliance Solutions for Payers

Navigant brings a combination of operational, compliance, clinical, coding, reimbursement, data analytic, HIPAA, cybersecurity and statistical professionals with extensive experience in Commercial and Government programs, supporting payer executives and their Counsel with regulatory compliance matters.   We bring an operational focus to achieving regulatory compliance; a solid understanding of regulator’s expectations coupled with the organizational design, process enhancement, and enterprise risk management experience to help plans efficiently achieve and sustain compliance.

Our services include:

Compliance and Enterprise Risk Management

  • Compliance Program Effectiveness Review and Compliance Program Organizational Design
  • eGRC (“Governance, Risk, Compliance”) Planning and Implementation including risk, policy, audit, compliance, privacy, business continuity and other oversight areas
  • Enterprise Risk Management program design and facilitation
  • Qualified Health Plan Assessments and Policy Development
  • CMS Annual Risk Assessments
  • Medicare Advantage and Part D “mock” CMS Compliance Program Effectiveness and Program Audits
  • Medicare Advantage and Part D CMS Audit Remediation
  • Medicare Advantage and Part D Independent Validation Auditors (IVA) and Sanctions Validations
  • Risk Adjustment Process Reviews and Coding Assessments
  • Delegation oversight program implementation and ongoing support to oversee First Tier, Downstream, and Related Entities
  • Compliance Due Diligence of acquisition targets
  • Independent Review Organization (IRO) Services

 Operations and Payment Compliance

  • Operational Process Improvement
  • Pharmacy Benefit Management (PBM) vendor selection and audits
  • Risk Adjustment process reviews, data validation and program design/implementation
  • Medical Loss Ratio accounting and audit/investigation support

Learn more about our solutions: Payer Mock Audits and Independent Auditor Services.  

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