Healthcare Payers

We support stakeholders across the managed care spectrum, ranging from local and regional health plans to health plans with nation-wide coverage; primary care providers taking on risk under capitated, delegated contracts; specialty provider groups navigating transitions to value-based care; and third-parties providing key services to each of these types of entities.

Our experts often work directly with C-suite executives in areas such as operational improvement, patient and provider engagement, data analytics, strategy, compliance, operational alignment and administrative efficiency. Our services also include core administration, audit and compliance, delegation oversight, network contracting, actuarial, pharmaceuticals, transactional due diligence and data management.

As risk management, cost efficiency, quality of care and member experience become equally emphasized, we help clients forge new relationships with providers, focusing on risk adjustment, population health/social determinants of health and health equity programs, value-based contracting models and delegated care management to achieve the goals of the “Quadruple Aim.” We help strategically plan for the necessary organizational transformation from a fee-for-service model, to one based on value that will enable you to adapt to the ongoing changes in the value-based healthcare landscape.

Health plans and managed care organizations often have a diversified membership base, from commercial and Medicaid entities, to ACA, Exchange and the self-insured. FTI Consulting’s team of experts can assist you in achieving your overall strategic business objectives, including efforts to assess investment in and alignment of strategic business units, translation of strategic objectives into operational transformation, and more-focused strategic reviews of specific markets and/or geographies.

Even the most well-run organizations may find themselves involved in disputes or the target of investigations. In addition to offering strategic support, we leverage our broad knowledge and deep experience in the healthcare industry to help organizations understand the risks these events involve, the underlying information the organization can use to combat these risks, and the strategic approach to help mitigate these risks.

Our experts work with internal and external counsel, compliance overall business leaders to best position an organization to respond to challenges posed by these events. Our experts understand the challenges that come with working in a highly regulated industry. We have worked with healthcare entities and the organizations that govern and monitor them (CMS, DOJ, OIG) to help arrive at resolutions that best support the needs of all parties involved, including providing expert testimony where needed.

We advise some of the largest and most successful payers, providers and services organizations in the Medicare Advantage marketplace to become more sophisticated in their use of data management, analytics and technology while constantly striving for greater operational efficiencies. As the industry and regulatory pressure grows, our experts help clients optimize the balance between improving performance and maximizing strong controls.

Our operational improvement expertise includes risk adjustment and quality/Stars programs, training in fee-for-service (FFS) and hierarchical condition category (HCC) coding, interim staffing and audit support, auditing and reconciling claims and encounters for reimbursement, creating and auditing “risk adjustment factor” (RAF) payment projections and adjustments, designing and developing analytics platforms targeting patients for recapture, and developing other data stores and “bridge” applications.

Our compliance and risk mitigation expertise includes designing and implementing effective governance practices, reviewing and developing leading-practice controls, policies and procedures, supporting clients and counsel through disputes and investigation support conducted by CMS, OIG, DOJ and other regulators, and providing expert witness support and testimony when needed.

Medicaid managed care companies are increasingly facing new program requirements. Yesterday’s innovations are today’s table stakes. Our team brings strategic and innovative thinking about the next generation of innovative programs and provider/community-based organization contract strategies. As State Medicaid regulators are enhancing oversight of their managed care partners, our services help clients outperform on the expectations of state regulators for operational excellence and compliance.

Since our team includes experts who have been seated at both sides of the table, we offer clients well-rounded expertise on operational assessments and improvement opportunities to address state actions and to prepare for procurements. Our deep compliance expertise includes developing subcontractor delegation oversight programs and independent compliance program reviews; ensuring coding and payment accuracy; and providing support in disputes and investigations. We also provide financial health assessments through review of reporting and data science/analytics, actuarial/rate-setting and risk-adjustment adequacy review, and pro forma development.

As Medicaid procurements become increasingly competitive, FTI Consulting’s Medicaid team offers end-to-end support to incumbent and new-entrant Medicaid managed care organizations. Services include market entry strategy, operational capabilities assessments and remediation road maps, program development, pre-procurement strategy, win theme and strategic partnership development, , writing and mock-scoring services, readiness review support, post-procurement debriefing and analysis of scoring, and bid protest support.

The employer-sponsored, commercial insurance business continues to be the dominant form of health insurance in the country. The introduction, and now expansion, of the ACA marketplace only adds to wide range of health plan offerings, risks and challenges in the commercial market. Having served in numerous health-plan leadership positions, our experts bring unique understanding to help clients provide focused solutions for key challenges facing commercial health plans in areas such as risk adjustment, value-based care, core operations, Third-party admin services, actuarial services, managed care contract negotiations, prevailing fee studies, utilization benchmarking, incurred but not reported (IBNR)/reserve setting, accountable care organizations, M&A due diligence support and audit/compliance reviews.

Pharmacy benefit managers and the environment they operate within are coming under increased scrutiny. Our multidisciplinary team of experts, including former PBM leadership with experience in managed Medicaid regulatory compliance, product development and operations, help PBMs remain in compliance and develop differentiated clinical programs to meet Medicaid needs with network strategies and clinical/social programs.

As Medicaid agencies continue to evolve their pharmacy programs, our experts help PBMs pursue new opportunities with both the Medicaid FFS program and with Medicaid managed care organizations. Our PBM Medicaid team offers end-to-end support to incumbent and new-entrant Medicaid managed care organizations. These services include market entry strategy, operational capabilities assessments and remediation road maps, program development, pre-procurement strategy, win theme and strategic partnership development, writing and mock-scoring services, readiness review support, post-procurement debriefing and analysis of scoring, and bid protest support.

We support our PBM clients as they respond to and remediate event-driven issues including internal accounting investigations, whistleblower lawsuits and commercial litigation. FTI Consulting has validated the adjudication logic and the claims engines that underlies some of the industry’s largest PBMs. We have also provided operational support to our PBM clients, helping to optimize their cost structure while building a platform for future growth.