When you need a Medicare Advantage expert…

Given the myriad of available managed care resources, it can be daunting to sift through the options and determine who is best qualified to develop solutions for your Medicare Advantage and Part D challenges.  Just as you would not trust your mother’s triple bypass procedure to a general surgeon, nor should you trust your Medicare Advantage or Part D program to anyone without years of relevant experience and impeccable credentials.  MCS can help make that process easier.

How does one identify a Medicare Advantage or Part D expert?  Many consultants claim to be “Medicare experts,” but look under the hood a little more closely.  Which part of the Medicare program do they have experience with, and how long have they worked in that area?  Medicare as a whole is a vast and highly complex federal program.  If there isn't significant experience directly with the Medicare managed care program (Medicare Advantage and its predecessors) over the years, chances are good that resource does not have the expertise needed to adequately assist you.  Hiring someone with years of NCQA experience to develop your Medicare QA program will not necessarily result in a compliant program.  Hiring someone who worked at CMS for years in the Medicaid space will do more harm than good for your Medicare Advantage program; Medicare and Medicaid are vastly different programs and are not a substitute for each other.

Can the consulting group you're considering offer both widely knowledgeable Medicare experts as well as MA or Part D subject matter experts (SMEs)? Medicare experts should be complemented by a team of veteran subject matter experts who know an aspect of the Part C or D program inside and out.  A well-rounded team of Part C and D experts and SMEs provide a holistic approach, focusing both on operational details as well as the bigger picture.

The team at MCS is comprised entirely of bona fide Medicare Advantage and Part D experts, as well as dedicated SMEs in many areas of the programs.    Every one of our consultants has spent anywhere from ten to almost thirty years exclusively in the Medicare managed care field, either working for Medicare health plans or with the Centers for Medicare and Medicaid Services (CMS).  Every MCS project has benefited greatly from the dual approach of industry and regulatory experience.  In addition to having the broad range of experience that entitles us to call ourselves Medicare experts, we each have specialized areas of expertise, from applications, appeals and grievances to compliance to enrollment and disenrollment, Prescription Drug Plan (Part D) Services to training as well as many others.

We carefully compile our project teams to meet the specific needs of each client and each project with the subject matter expertise needed for that engagement. Call us to discuss the exact resources your organization needs.


CMS requires sponsors to conduct a formal baseline assessment of their major compliance and FWA risk areas, such as through an annual risk assessment. Having a “best in class” risk assessment process allows you to identify and risks and correct identified problems before they escalate. MCS has created and revised Medicare annual risk assessment processes that include industry best practices.  This ensures that the compliance program includes all the required components and that processes can be implemented within each client’s organizational structure.


The CMS application process is time-consuming, labor intensive and requires laser attention to detail.  It also requires familiarity with the CMS process.  Many entrants in the Medicare market find the application process overwhelming, but it doesn’t have to be.  MCS experts have prepared applications in their previous roles as health plan staff and have reviewed applications in their former roles as CMS regulators, from the early 1990s when it was largely a paper process.  In our many years of preparing and assisting with applications as Medicare consultants, not one of them has been denied. MCS provides a highly efficient and organized application process, making it a much easier endeavor. We will create an application work plan specific to the type of contract(s) you plan to offer.


CMS has been publishing its audit protocols for the past five years, as well as numerous other resources on their audit requirements and expectations.  In short, they have given out the answers to the test.  Yet many Medicare plans have poor CMS audit results.  Since 2012, enforcement actions by CMS have doubled.   More plans are subject to suspension of enrollment and marketing activity, and civil monetary penalties are getting larger.

Many Medicare plans do not have the resources, knowledge or experience to create effective internal audit programs.  MCS works with each client to understand its internal organizational structure and develop effective Medicare audit programs that work within that structure.



The CMS audit process is complex and continually changing.  Although CMS releases its updated audit protocol to the industry each year, there are many factors that send a CMS audit off the rails.   Many organizations, upon receiving notification from CMS of an impending audit, are uncertain how to prepare and proceed through the audit process. MCS’s consultants have a combined total of over 60 years participating in CMS audits, either as former CMS regulators in charge of conducting audits, or as seasoned Medicare health plan veterans who have succeeded in navigating through CMS audits. Sharing our experience and insider knowledge of the process with an organization facing a CMS audit results in a smoother audit experience and ultimately a more successful audit outcome.



CMS requires Medicare Advantage and Part D Organizations to audit and monitor First Tier, Downstream and Related Entities (FDRs) that are involved in the administration or delivery of Medicare Part C and Part D benefits.  This has been an increasing area of scrutiny by CMS in recent years.  MCS develops and implements FDR oversight programs that fully document compliance to CMS and to your Board of Directors.  At the end of the project the client is provided with a comprehensive program that includes monitoring, auditing, and other types of oversight activities at all levels (operational, compliance and executive oversight), policies and procedures, and review tools. 



Losing a key Medicare staff member in operations or compliance is disruptive and leaves the organization at risk.  And given the complexity of the Medicare Advantage and Prescription Drug programs, it is not always easy to immediate identify a qualified replacement.  MCS can fill the void for clients by embedding a subject matter expert in the organization, either virtually or onsite, for whatever period of time is needed.  Our experts have served as interim Medicare Compliance Officers, Directors of Enrollment, and Directors of Appeals and Grievances, among other positions, ranging from a few weeks to many months. It takes time to fill positions with qualified candidates, and in this ever-changing industry, the risks of leaving key positions vacant during the search process is fraught with risk. 



Navigating Medicare marketing material requirements has become increasingly complex over the years. What started out as a 36-page set of guidelines in the early 1990s has blossomed into nearly 120 pages of requirements and guidance on everything from disclaimers to testimonials to use of the Medicare mark on member ID cards.   Many organizations feel ill-equipped to develop materials that can pass muster with CMS given the wide-ranging and often arcane marketing guidelines.  MCS provides clients assistance during the marketing material development stage and can serve as the compliance marketing review function throughout the year or during AEP as needed.



CMS requires organizations to conduct ongoing monitoring activities on its internal Medicare operations.  Medicare plans have a considerable amount of data that can be used to assess whether day-to-day operations are compliant with basic requirements. Much of this data is accessible by CMS and is the first line of site into operational and accessibility issues. Without an organized, comprehensive monitoring program in place, however, the advantage of detecting early warning signs of non-compliance is lost and often small problems escalate into serious compliance deficiencies that may not be detected until an audit is conducted, either by the organization or by CMS. MCS experts have experience creating Medicare monitoring programs and compliance dashboards that harness the information necessary to provide compliance status at-a-glance to compliance officers and senior management.



Once the initial or service area expansion application has been submitted to CMS, the real work begins.  It takes knowledge, experience, and an investment of considerable resources to implement a compliant Medicare program.


The foundation of strong Medicare operations includes detailed and compliant policies and procedures (P&Ps). MCS subject matter experts review your current P&Ps to determine if they meet CMS requirements and assist in revising them and developing any new P&Ps that may be necessary based on HPMS memos, manual chapter, and/or regulatory guidance.



We help clients de-mystify Part D administration and the complex maze of regulatory requirements to ensure compliance.  We provide our clients with industry best practices by drawing from our years of audit and operational experience with numerous Medicare drug plans across the industry.



CMS bombards the Medicare Advantage industry with frequent, sometimes daily, changes to requirements and guidance must be implemented quickly and effectively.. MCS experts refine, reengineer, and streamline processes to achieve significant levels of improvement in quality, time management, efficiency, compliance and profitability.



Training is crucial for organizational development and success, and is the starting point to achieve compliance with regulatory requirements.  Training and re-training employees, both new and experienced, is an ongoing process.  Whether you need training content or face-to-face training, we have subject matter experts experienced in creating and delivering highly effective training programs in all areas of the Medicare Advantage and Prescription Drug programs.