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Establishing and implementing necessary structure and procedures
Medicare Compliance Officer advice and consultation
Coordination and cooperation with in-house counsel
Ongoing consultation on a retainer basis
Updating policies, procedures, and forms to meet changing regulatory requirements
Liaison and routine dealings with CMS
Medicare Compliance and Quality Improvement Committee
Performance oversight and Reporting-Legal Issues
Fraud, Waste, and Abuse Policies and Procedures and Control Programs
CMS Monitoring and Reporting Issues
State/Federal Regulatory Issues
Appeals and Grievances
CMS requires adoption of proper policies and procedures to provide for processing of appeals from denial of claims, complaints regarding agents or claims handling practices, or grievances. The firm is available to assist in any regard with respect to Appeals and Grievances Policies and Procedures, whether to provide a template and adapt the form to the particular client, review an already existing plan, or advise concerning ongoing operations.
Proper policies and procedures for appeals and grievances is not only required for Federal regulatory compliance with CMS requirements, but some form is also required by State regulatory agencies as well, and is generally advisable to minimize the insurer's liability for alleged bad faith or unfair claims handling practices. By providing an established procedure for review of claims handling at the primary level, it provides a check and balance, and due process for review of claims.