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Health Care Case Study

Case #12002: Medicare Part D Compliance

The Senior Services division of a national Health Benefits Organization was anticipating growth in its Medicare Advantage and Supplemental membership by over 12% and was entering the Medicare Part D market with open enrollment. Questas was engaged to provide managerial support to the Compliance Department and assist with the initial set up and infrastructure development for a Medicare Part D Compliance process.

The Compliance Department was chartered to provide regulatory oversight for the Medicare Part D, Medicare Advantage and Medicare Supplement products as well as supportive activities to the Sales and Marketing departments. The Compliance department did not currently have the resources, infrastructure or processes in place to achieve compliance or report on the status of attainment.

Engagement Highlights

  • Industry:
  • Health Insurance
  • Client:
  • A National For-Profit Health Benefits Organization
  • Assignment:
  • Provide Managerial support to the Regulatory Oversight activities of the National Health Plan's Senior Services Operations
  • Get and then keep the operations up-to-date on changing federal and state regulations
  • Oversee the activities of the analysts within the unit
  • Assist in creating a staffing plan to fill the existing gaps and holes in the compliance staffing model
  • Begin implementation of the processes, reporting, staffing models, resource alignment and infrastructure to achieve compliance for Medicare Part D processing
  • Approach:
  • Conduct and participate in semi-weekly meetings hosted by various regulatory agencies, departments and related associations
  • Communicate all key changes during regular operations meetings
  • Coordinate with operational areas to ensure processes are in place to achieve compliance throughout the Part D set-up, enrollment and implementation period
  • Oversee compliance analyst activities and coordinate future assignments for analysts with V.P. of Compliance
  • Duration:
  • 14 months


  • Developed processes, procedures, workflows, staffing models, reporting and infrastructure to gain Medicare Part D compliance
  • Reorganized the Compliance Department, established required staffing levels and filled needed positions to coordinate MA, MS and Part D compliance requirements
  • Implemented auditing to monitor operational compliance
  • Developed a plan to assist ongoing regulatory oversight support
  • Currently achieving CMS compliance

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