Guidehouse Commercial Payer

Commercial Payer

Commercial Payer

Risk, Regulatory & Compliance

Risk, Regulatory & Compliance Solutions for Payers

The Guidehouse Payer practice brings together compliance, operational, audit, clinical, coding, data analytics, and system professionals who have extensive experience in performing Commercial and Government program projects and who have supported payer executives and their Counsel with regulatory compliance matters.

The Guidehouse Payer practice has worked with numerous health plans to perform annual risk assessments, develop and implement Corporate and Government Programs compliance programs, perform ongoing monitoring and auditing, and assess the effectiveness of all facets of a compliance program and health plan operations. Our services include:

Compliance and Audit

  • Compliance Program Effectiveness Review and Compliance Program Organizational Design
  • CMS Annual Risk Assessments
  • Policy and procedure development
  • Medicare Advantage and Part D “mock” CMS Compliance Program Effectiveness and Program Audits
  • Medicare Advantage and Part D CMS Audit Remediation and Corrective Action Plan (CAP) development
  • Medicare Advantage and Part D Independent Validation Auditors (IVA) and Sanctions Validations
  • Risk Adjustment Data Validation (RADV) audits
  • Delegation oversight program implementation and ongoing support to oversee First Tier, Downstream, and Related Entities (FDRs)
  • Fraud, Waste, and Abuse (FWA) program development and implementation
  • Compliance Due Diligence of acquisition targets
  • Independent Review Organization (IRO) Services

 Operations and Payment Compliance

  • Operational Process Redesign and Improvement
  • Pharmacy Benefit Management (PBM) vendor selection and audits
  • Risk Adjustment End-to-End process reviews, clinical coding assessments, and program design/implementation support


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