Detailed Service Description

Click on any of the services below to get additional information about our services structure and engagement approach

Discrepancy and Revenue Recovery Analytics and Clean-up Support for Enrollment, Special Status and Coordination of Benefits
Madena’s reconciliation software results from decades of industry experience understanding and interpreting CMS & state data files. Our comprehensive algorithms compare your system data to government files and identify discrepancies where many other systems may fall short. We excel working with clients who have multiple systems and varying data infrastructure. Let us put our software solution and reconciliation experts to work for your organization.

Our Expert Team will:

  • Reconcile Enrollment and Billing between plan system and government files
    • Perform one-time reconciliation analytics
    • Perform ongoing reconciliation analytics with flexible contract terms
    • Perform a true reconciliation for the relevant time period
    • Resolve historic and present enrollment discrepancies
    • Follow-up consulting to aid in CMS resolution
  • Provide comprehensive solutions engineering
  • Provide small to large-scale data mining, analysis and management

Many organizations have a need for temporary or long-term support for enrollment, billing & discrepancy clean-up services. Using your reconciliation solution or ours, our expert team will:

  • Perform one-time reconciliation clean up of enrollment, special statuses, premium billing and Coordination of Benefits (COB) & Medicare Secondary Payer (MSP)
  • Offer ongoing reconciliation support with flexible contract terms
  • Support temporary high volume activity during open enrollment or service/contract expansion
  • Provide temporary support during staff turn-over or unexpected high volume times

Our analytic services provide for an exceptional Return on Investment (ROI) to our clients. In an environment of slim – and shrinking – margins, can you afford not to use our discrepancy analytic and clean-up services?

Comprehensive Operational Assessment and Remediation Services
Let us apply our industry-leading knowledge and assessment protocols to evaluate your operations. We have worked extensively with 5-STAR plans to create best practices to help drive their success. Our assessments focus on what you are doing well as well as identifying your operational & system gaps. Our veteran analysts will assess the staff, processes, documentation and systems for the following:

  • Call Center Operations
  • Enrollment, Eligibility and Reconciliation
  • Premium Billing
  • Grievance & Appeals
  • Claims
  • Quality Assurance Programs
  • Delegation Oversight Programs

Our approach is comprehensive and can be tailored to your needs:

  • Side-by-side reviews with your staff
  • Knowledge testing of the staff
  • Evaluating the efficacy and accuracy of your current quality assurance and monitoring processes
  • Trace the end-to-end of each process by looking at the inputs, process, and outputs
  • A documentation review for completeness and accuracy
  • Evaluation of training modules for completeness and accuracy
  • Evaluation of reporting to ensure:
    • Visibility into your KPIs
    • Effective monitoring to reduce your compliance risk

The end result report provides you with a comprehensive document of each area assessed:

  • What your organization is doing well
  • Inefficiencies that are driving up your administrative costs
  • Areas of high risk
  • Compliance gaps

Where you may have gaps or lack of confidence in your system, reporting, and metrics, our services can give you the confidence and transparency you need.

  • One-time or ongoing audits of your internal operations and vendors/delegated entities,
  • One-time or ongoing compliance dashboard reporting and KPIs
  • Independent certification & attestation reporting of your existing processes and reconciliation technology

New Plan, Expansion and System Implementation Services
If you are considering offering a new government-sponsored health plan, are expanding your current benefits or service offerings, or are implementing a new system infrastructure, our experts are your one-stop-shop. We have extensive experience establishing the people, processes and technology from the ground-up in the following areas:

  • Call Center Operations
  • Enrollment, Eligibility and Reconciliation
  • Premium Billing
  • Grievance & Appeals
  • Claims
  • Quality Assurance Programs
  • Delegation Oversight Programs

Our approach is comprehensive and can be customized to fit your needs and augment your staff and government programs expertise to ensure a successful launch. We have experience in:

  • Buy vs. Build evaluations
  • RFP development and evaluation
  • New plan and expansion project management
  • Vendor recommendations
  • Vendor contracting and pre-delegation audits
  • Developing business requirements
  • Developing technical/functional specifications
  • Developing current state, future state, and system workflows
  • Developing cross-functional integration models that manage the end-to-end process
  • Creating operational documentation and training materials
  • Readiness assessments
  • Providing clear and comprehensive expertise during all stages of your implementation, based firmly in our understanding of regulations and industry best practices

We have worked extensively with many vendors in the government-sponsored health care arena and can assist you in the daunting task of implementation and post-go-live support. We excel in finding the right vendor for your program and work with both to help in the translation of requirements into implementation. Your success and profitability depends on maximizing the functionality and integrating the system with your current infrastructure.

Customized Solutions to Create a Solid, Efficient and Compliant Medicare Operations Team
Whether you are a new plan or a veteran to government programs, we offer custom solutions specific to your operational needs and interests. We focus on integrating CMS compliance regulations into your management and operations and work to make sure your staff understands how to apply the regulations to day-to-day operations through:

  • In-person or remote consulting
  • Policy development (including job aids and desk level procedures)
  • Training development – new employee and annual training
  • Knowledge assessments
  • Onsite or remote training programs
  • Web-based, self-guided training programs
  • Audit-readiness preparation

Finding the right people to create a strong, compliant workforce isn’t a nice-to-have; it’s a must! We are passionate about building you a solid and sustainable operations team.