Medicare Consulting

Madena Solutions > Services > Consulting > Medicare Consulting
Expert Advising, Education, & Management

Madena’s suite of end-to-end Medicare consulting services supports all of your government healthcare operations. We offer comprehensive strategies and solutions for new and existing Medicare Advantage plans.

Wherever your company is in the development process, whatever your challenges, we’ve got the experience and tools to help you stay compliant, grow your business, and succeed.

Implementing a new Medicare Advantage health plan? Expanding your current benefits? Our experts are your one-stop-shop. We offer systems development, operations management training, and quality assurance—all customized to your needs and based firmly in our understanding of CMS regulations and industry best practices.

From implementation to post-go-live support, we’ve got your back.

Our veteran analysts will provide you with customized, comprehensive reports and practical solutions and action steps. We also perform Independent certification and attestation reporting of your existing processes and reconciliation technology.

Understand your Operations System inside out, so you can confidently move forward.

Does your Ops team need an upgrade? We facilitate live or web-based education and training, evaluation of current practices, and team development.

We are passionate about building you a solid and sustainable operations team.

To learn more about Madena’s audit support services or to request a proposal, please contact us at 855-990-2639 or email

Program Audit

Health plans should expect a CMS Program Audit at any time. Turnaround times are short; from Engagement Letter to Universe submission, plans only have 15 days to complete the audit.

Madena can assist with ODAG & CDAG Universe Preparation and Testing and CPE Universes creation and review. We also conduct Mock Audits using current CMS Program Audit Protocols to prepare your staff for the real thing. We provide detailed result reports and assist with any necessary Root Cause and/or Impact Analysis.

Program Audit – Preparation is critical

Timeliness Monitoring

In October CMS issued a memo regarding the 2020 Timeliness Monitoring Project (TMP). As in previous years, CMS will be conducting an industry-wide monitoring project by collecting data to evaluate the timeliness of processing Medicare Advantage (Part C) organization determinations and reconsiderations and Medicare Prescription Drug (Part D) coverage determinations and redeterminations.

Being aware of the issues within your data is critical to maintain Star Ratings. Madena can help your organization get ready for the TMP.  Download our white paper, below, for an in-depth look at the TMP.

CMS 2021 Timeliness Monitoring Project

Informal Operations Review

CMS may ask their Regional Offices to conduct informal operational reviews of their health plans, which will include the following: a notice of review, universe pulls (with no published/prescribed data elements), virtual reviews via webinar, and onsite visits.

Call Center, Enrollments, Disenrollments, Broker Sales, OEV, mail room processing, and other departments have been included in these reviews. You will have just one week to respond with data and be webinar ready.

Contact us for an independent assessment of your readiness, risk, and gaps. We can assist with data pulls and staff webinar preparation, operations review, and conduct a mock review.

Informal Operation Reviews – The lastest review from CMS

Provider Data Accuracy

Incorrect provider data has negative downstream affects for both members and plans. Members rely on the information in provider directories, and inaccuracies could pose a significant access-to-care barrier. CMS may issue compliance actions as a result of directory inaccuracies.

Madena’s subject matter experts (SMEs) can provide guidance and perform data validation audits to identify data quality issues and mitigate compliance actions.

Learn more about what you can do to improve your provider data accuracy with our downloadable guide.

Provider Data Accuracy – why is it important?

Call Center Audit & Monitoring

CMS conducts regular Call Center Monitoring for Part C and D plans, which focuses on call response timeliness, accuracy, and accessibility. The results of a monitoring study may result in notices of noncompliance for health plans that fail to meet the regulatory requirements.

Madena suggests all health plans implement call metric reporting and monitoring to identify and address any gaps. Our SMEs can craft performance guidelines and conduct audits to make sure your plan is in compliance.

Call Center Monitoring for Part C and Part D plans in 2020

FDR Audits

CMS requires health plans to develop a strategy to monitor and audit their First Tier, Downstream, and Related entities (FDRs) to ensure that they are in compliance with all applicable laws and regulations.

Madena’s SMEs can help you develop a monitoring strategy, assist with risk assessment, and perform pre-delegation site visits and annual delegation audits of your FDRs.

First Tier Downstream Related Entity Compliance

Part C/D Reporting

CMS has specific reporting requirements for Medicare Advantage Organizations (MAOs). Each MAO must have an effective procedure to develop, compile, evaluate, and report this required information to CMS in a timely manner. CMS publishes an annual Reporting Requirement and Technical Specification document to guide health plans, but it’s a lot of information and it changes almost every year.

Madena has SMEs to guide you through all the regulations, help document your processes from end-to-end, and ensure your data is valid and reliable.

Part C&D Reporting – How Madena can support you

Data Validation Auditor

The Medicare Part C and D Data Validation Audit (DVA) regulations require Medicare Advantage Organizations (MAOs) and Part D sponsors to contract with an independent external data validation auditor to review the process and data that is reported to CMS.

Madena is certified as a Data Validation Auditor through CMS training and testing. Our SMEs have a thorough, demonstrated understanding of Title I and II of the Medicare Modernization Act (MMA), Medicare Part C and D regulations, the Medicare Managed Care Manual, the Prescription Drug Benefit Manual, and Part C and D reporting requirements and technical specifications.

Data Validation Audit

Independent Validation Audits

Following a Program Audit, CMS may require an Independent Validation Audit (IVA). Madena’s subject matter experts have years of experience with Medicare compliance audits and will guide you efficiently through the Validation Audit process.

Independent Validation Audits – What’s Possible after a Program Audit

To learn more about Madena’s audit support services or to request a proposal, please contact us at 855-990-2639 or email