CONSULTING AND SOFT WARE SOLUTIONSFOR MEDICARE, MEDICAID, AND THE HEALTH INSUR ANCE MARKETPL ACES

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Gorman Health Group (GHG) is your trusted partner in excellence

for government-sponsored health programs through a compliant,

member-centric focus and recognition of Medicare, Medicaid, and now the Health Insurance Marketplaces as mission-critical customers.

We began as a compliance boutique, helping health plans and providers avoid trouble and find success in the government sector. We soon recognized companies with strong operations and execution of regulatory minutiae don’t get into trouble to begin with, so we rapidly expanded our capabilities as fixers‒the “plumbers under the sink.” Since our inception in 1996, we have provided strategic, operational, financial, and clinical services to the industry across a full spectrum of business

needs. Today, our innovative software solutions power the industry’s leading compliance shops, sales and marketing functions, enrollment departments, quality improvement, and revenue management operations to help them meet their goals. We pride ourselves on having both day-to-day alignment with the latest federal and state guidance and the long-term strategic vision to keep it all in perspective.

Now and in the future, Medicare, Medicaid, and the Health Insurance Marketplaces are the leading sources of revenue and earnings for insurers and providers alike. Mastering these programs and the dizzying regulatory complexities they bring is the key to survival and prosperity in our industry. Our expert model consultancy is also our sandbox, where consistent challenges our clients face are brought forth for software and outsourcing solutions. Our mission is to empower health plans and providers to deliver higher quality care to members at lower costs while serving as valued, trusted partners. We combine innovation with proven, integrated approaches and technology solutions to help you reduce costs, improve quality, and optimize revenues.

Disruptive events like healthcare reform present both tremendous opportunities and threats to payers and providers alike. Let GHG be your trusted partner in Medicare Advantage (MA), Part D, Medicaid, and the Health Insurance Marketplaces. We’ve been there, fixed that, and will ensure your success.

SUCCEED IN THE CHANGING HEALTHCARE LANDSCAPE

OUR VISION FOR EXCELLENCE

IN GOVERNMENT-SPONSORED HEALTH PROGRAMS

JOHN GORMANFounder & Executive Chairman

ONE-STOP ACCESS TO EXPERT ADVICE, GUIDANCE, AND SUPPORT IN EVERY STRATEGIC AND OPERATIONAL AREA

We are your partner in government-sponsored health programs

Operational Performance Bringing excellence to every aspect of your implementation, from enrollment to claims payment.

Sales Sentinel™ is a module-based software solution designed to assist government managed care organizations onboard agents, provide training, manage ongoing oversight activities, and pay commissions effectively and compliantly.Strategy & Growth

Driving profitable growth and member retention through strategic marketing, sales, and product development.

Provider InnovationsSupporting network design and medical cost control implementation.

ComplianceOffering guidance and support in every strategic and operational area to ensure alignment with the Centers for Medicare & Medicaid Services (CMS) and state Medicaid programs.

Healthcare Analytics & Risk Adjustment SolutionsAssessing, designing, and implementing cross-functional risk adjustment programs with corporate initiatives for medical trend management and quality improvement.

PharmacyLeading experts in Part D, pharmacy benefit management, formulary, and pharmacy programs.

Clinical, Quality & StarsChanging how you approach Medical Management, Quality, and Star Ratings.

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The Point™ provides a clean and concise view of constantly updated content, delivering all the industry information you want when you need it.

Gorman University™ provides training sessions on a varety of industry topics, each designed to meet the unique needs of your organization.

Valencia™ provides rigorous, compliant, and transparent workflow controls that ensure your operational processes – and the resulting payment – are as accurate as possible.

CaseIQ™ not only captures all of the data points needed to categorize, work, and report MA and Part D appeals and grievances, it also guides case processors through each case to minimize the risk of non-compliance due to user error.

OMT™ is the complete compliance toolkit designed to perform ongoing monitoring and auditing, manage regulatory notices, document corrective actions, and streamline member material review.

One-stop access to expert advice, guidance, and support in every strategic and operational area.

CONSULTING SERVICES

Compliance is not a job function like enrollment or medical management - it’s an attitude. It’s how we got our start and remains the core of what we do. Compliance permeates every department and must be supported by effective tools and rigorous oversight. The long-term effects of non-compliance include impact to Star Ratings, public scrutiny, loss of membership, money penalties, a CMS-imposed freeze on marketing and enrollment, and even contract termination. Leveraging health plan as well as state and federal agency experience, our team of Compliance experts will help you establish an effective compliance program, including the implementation of early warning systems to ensure operational inefficiencies and compliance risks are identified immediately.

COMPLIANCE NON-COMPLIANCE COSTS ARE TOO BIG TO IGNORE

Application Support Ongoing assistance through every step of the process, from project management and gathering the right data to submission and follow-up response.

Delegation Oversight Provide in-depth delegation oversight assessments and program establishment to proactively identify risks and opportunities for improvement.

Audit Preparation Evaluate your staff’s readiness for a CMS audit, ensuring all participants are prepared.

Audit Remediation Services Deliver comprehensive corrective action work plans and develop/implement compliant processes.

External Audit Program Ensure adherence to your audit work plan, fully customizable to include internal and first tier, downstream, and related entity (FDR) audits dependent on your needs.

Annual Risk Assessment Evaluate MA/Part D functional areas to determine best-practice solutions, organization risks, and needed remediation.

WE SPECIALIZE IN THE FOLLOWING:

WE SPECIALIZE IN THE FOLLOWING:

GHG’s team of veteran pharmacy experts can help your Part D plan operating in Medicare, Medicaid, and the Health Insurance Marketplaces develop and implement efficient and compliant internal Part D operations that focus on best practices and current state-of-the-art strategies. Our broad array of tools and services can assist you in audit preparation, remediation and validation, delegation oversight and monitoring, Pharmacy Benefit Manager (PBM) audits, PBM contracting and implementation, benefit testing, rejected claims review, interim staffing, clinical process re-engineering, Star Ratings improvement, and claims and prescription drug event (PDE) assessment and adjustments.

PHARMACY THE CHALLENGES ADDRESSING PART D PROGRAM COMPLIANCE RISKS

Delegation Oversight & Monitoring Provide in-depth delegation oversight assessments to help your organization learn where and how to verify potential issues and identify risks.

Benefit Administration Testing Create and conduct an in-depth benefit administration test plan for your organization to validate effective operations and ensure your PBM is processing claims consistent with your CMS-approved formulary.

Part D Operations Expert guidance related to regulatory and operational issues to help alleviate risk for the prescription drug benefit program and improve Part D Star Ratings.

Audit Prep, Remediation & Validation Assist with universe quality review, sample selections, and mock webinars to prepare your organization for audit. Offer support during the audit and assist with post-audit remediation.

PBM Oversight Assist with ongoing PBM monitoring and oversight through the design of a customized sampling and review program. Develop the methodology and provide a team for an annual PBM onsite audit.

PBM Solicitation Management Create a custom Request for Proposal (RFP) and assist with the scoring, selection, and implementation of a PBM.

A new vision for maximizing healthcare analytics and optimizing risk adjustment programs to ensure accurate reimbursement for plans operating in Medicare, Medicaid, and the Health Insurance Marketplaces.

Our Healthcare Analytics & Risk Adjustment Solutions team supports our clients in evaluating the efficiency, integration, strategic value, and overall compliance of risk adjustment programs from start to finish. Streamline the execution of your risk adjustment approach and build a roadmap to ensure you’re keeping pace with CMS expectations in both compliance and healthcare outcomes.

HEALTHCARE ANALYTICS & RISK ADJUSTMENT SOLUTIONS LEVERAGING ANALYTICS, DRIVING PERFORMANCE, OPTIMIZING REVENUE

Reduce Audit & Financial Risk Anticipate regulatory changes and execute a comprehensive quality assurance program to reduce/mitigate audit risk and overpayment exposure. Maximize Analytics Leverage existing technology and data for enterprise-wide solutions for risk adjustment, medical management, and quality improvement.

Optimize Revenue Provide end-to-end support to help plans deliver high-quality care, manage increasing healthcare costs, and achieve payment accuracy.

Drive Performance Evaluate the efficiency and strategic value of risk adjustment programs and vendor partnerships to ensure timely and complete data flow.

Manage Medical Trend Facilitate creation of cross-departmental action plans to identify opportunities to reduce utilization and manage the cost of care for your patients and beneficiaries.

WE SPECIALIZE IN THE FOLLOWING:

Your network is a critical part of your product, and your contracting strategies for Medicare, Medicaid, and the Health Insurance Marketplaces should reflect it. Since 1996, we have provided powerful insight, expertise, and solutions to physician group leaders in government-sponsored health programs.

PROVIDER INNOVATIONS SUPPORTING NETWORK DESIGN AND MEDICAL COST CONTROL IMPLEMENTATION

Payment Innovation Review and implement options for innovative, value-based provider reimbursement strategies.

Narrow Network Analysis Measure your network’s productivity to pinpoint which type of payment pattern works for you.

Interim Management Provide expert staffing and “boots on the ground” in network and contracting operations.

Clinical & Financial Integration Develop some of the most innovative implementation strategies, bonus, and incentive arrangements in the industry.

Accountable Care Organization (ACO) Implementation & Support Provide the tools, processes, and expert guidance to drive overall performance.

Network Development Assess the alignment and track the results of your products, your current network, your market, and your network requirements.

Network Compliance Offer in-depth provider directory and network analysis to comply with Medicare, Medicaid, and the Health Insurance Marketplaces regulations.

Our teams of experts assess the viability of health plan contracts, examine the feasibility of launching your

own insurance company, and implement best practices to help you realize the promise of value-based care.

WE SPECIALIZE IN THE FOLLOWING:

PROVIDER INNOVATIONS SUPPORTING NETWORK DESIGN AND MEDICAL COST CONTROL IMPLEMENTATION

In order to positively impact quality and financial outcomes, health plans must prioritize clinical capabilities as part of their goal to provide the best care to members, strengthen provider relationships, and drive overall plan performance.

CLINICAL, QUALITY & STARS CHANGING HOW YOU APPROACH MEDICAL MANAGEMENT, QUALITY, AND STAR RATINGS

MOC Development & Redesign Assure your plan’s Model of Care (MOC) is positioned to accomplish the goals and outcomes a Special Needs Plan’s (SNP’s) performance demands.

Medical Management Ensure effective strategies are in place through best-practice application targeted at reducing administrative costs through our support and expertise.

NCQA/HEDIS Evaluation & Strategy Analyze your HEDIS® data for gaps and identify interventions for your health plans, providers, and members.

Star Ratings Assessments Provide overall evaluations of strategies, gap closure solutions, and management of clinical quality outcomes.

Interim Management Offer clinical leadership experts when and where you need them.

Quality Improvement Create and evaluate quality performance programs and provide solutions for better processes to ensure outcome improvements.

Our clinical team of experts can assess your current quality program and develop integrated strategies

to build a new foundation focused on collaboration that maximizes clinical outcomes and compliance in

Medicare, Medicaid, and the Health Insurance Marketplaces.

WE SPECIALIZE IN THE FOLLOWING:

Achieving quality improvement and risk score accuracy has never

been more critical to health plan competitiveness and viability.

Our clinical team of experts can assess your current quality program and develop integrated strategies

to build a new foundation focused on collaboration that maximizes clinical outcomes and compliance in

Medicare, Medicaid, and the Health Insurance Marketplaces.

WE SPECIALIZE IN THE FOLLOWING:

Our teams of experienced senior operations consultants assist dozens of health plans operating in Medicare, Medicaid, and the Health Insurance Marketplaces each year in improving processes and scrubbing their member data. We can translate your business strategies into practical, efficient, and rigorous work processes with the highest degree of compliance and accountability. Our experience with virtually every software application and service vendor enables us to share procedural practices and audit metrics with your organization to ensure workflows and infrastructure are best in class.

OPERATIONAL PERFORMANCE EXCELLENCE IN EVERY ASPECT OF YOUR IMPLEMENTATION, FROM ENROLLMENT TO CLAIMS PAYMENT

Root Cause Analysis A comprehensive service focused on helping you identify and address the immediate operational problems and uncover the root cause behind it.

Implementation Provide detailed knowledge of state and federal requirements for successful and compliant implementation.

Process Improvement In-depth analysis of your organization’s current business processes to ensure your workflows and systems are best in class.

Interim Management Offer strategic, operational, financial, and clinical leadership experts when and where you need them.

Operational Assessment Review of your day-to-day operations to ensure processes are accurate, running efficiently, and compliant.

Reconciliation/Revenue Management Provide transparency into your premium reconciliation functions by scrubbing internal data to identify optimal reimbursement opportunities.

We will implement a detailed roadmap for your organization to move from strategy into implementation and find long-term success.

The pressure is on for health plans to optimize revenue, cut costs, improve member- patient outcomes, and control medical spend. Our teams of Sales and Marketing specialists are focused on helping health plans participating in Medicare, Medicaid, and the Health Insurance Marketplaces evolve their critical business practices to drive profitable growth through our strategic marketing, sales, and product development expertise. Together, we will design and implement a strategy that examines your service area, market, environment, and core competencies to maximize product potential and position your organization competitively for future success.

STRATEGY & GROWTH DRIVING PROFITABLE GROWTH AND MEMBER RETENTION THROUGH STRATEGIC MARKETING, SALES, AND PRODUCT DEVELOPMENT

Feasibility & Viability Analysis Provide an in-depth analysis of the cost of entry and industry risk/reward, whether you’re getting into MA for the first time or deciding if your plan is ready for a service area expansion. Product Development & Benefit Design Design and implement a comprehensive data analysis to guarantee you have the right products, programs, and capabilities in place to compete and ensure you are go-to-market ready.

Sales, Marketing & Retention Strategy Provide cost-effective, member-centric strategies to achieve maximum return on your investment.

Sales, Marketing & Retention Assessment Conduct an end-to-end analysis of what’s working and what’s not within your current sales and marketing plan and provide best practices to effectively drive growth and retention.

Interim Management Offer go-to-market, strategic, operational, and financial leadership experts when and where you need them.

WE SPECIALIZE IN THE FOLLOWING:

We offer enterprise-wide software solutions to stay compliant, optimize revenues, and manage complex processes. Several GHG products are considered “best in class” by CMS.

PRODUCT SOLUTIONS

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Sales Sentinel™ is a flexible module-based software solution designed to assist government managed care organizations onboard agents, provide training, manage ongoing oversight activities, and pay commissions effectively and compliantly. Because every organization is unique, Sales Sentinel™ can be licensed as a complete solution or tailored to address specific needs.

ONE-STOP SHOP FOR AGENT MANAGEMENT SALES SENTINEL™ IS QUICK, EASY AGENT ONBOARDING, TRAINING, AND OVERSIGHT

Evaluate how Sales Sentinel™ can help you automate:

Contract and document completion

License checks

Background checks

Appointments

Delivery of plan-specific benefit training

Delivery of annual certification training or verification of equivalent training, such as America’s Health Insurance Plans (AHIP) for Medicare or verification of CMS annual certification for the Health Insurance Marketplaces

Agent ID / writing code assignment

Monthly Office of Inspector General (OIG)/General Services Administration (GSA) checks

Ongoing automated agent communications

Reporting, including annual required Part C and Part D Health Plan Management System (HPMS) metrics

Ongoing agent oversight, including rapid disenrollment rate tracking, allegations, disciplinary actions, and agent-related Complaint Tracking Module cases (CTMs) in the Oversight Module

The ability to generate agent commissions according to CMS MA/Part D requirements without transferring data between multiple systems in the Commissions Module

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KEY FEATURES OF SALES SENTINELTM

ONBOARDING Ensure agent is contracted, licensed, trained, appointed, and ready to sell. OVERSIGHT Accommodates to any organization’s agent oversight program. COMMISSIONS A quick and easy solution for organizations to generate commissions payments.

OMT™ tracks hundreds of performance indicators in real time. It’s not just software, its a philosophy – operations managers must be accountable for their team’s performance. Integration between modules allows for the connection of metrics, documentation, and requirements, as well as corrective actions, regulatory notices, and audits. Core functionality is enhanced by the addition of GHG-maintained content, including documents, elements, and audit tools such as integrated CMS-style worksheets. Track HPMS memos, manage marketing materials, and much more. The OMT™ supports the complete organization by bringing a new level of transparency to performance monitoring, including the required oversight of delegated entities.

AUTOMATING COMPLIANCE BRINGING A NEW LEVEL OF TRANSPARENCY TO PERFORMANCE MONITORING

OMTTM MODULES MAKE IT EASY TO CONNECT TO DAY-TO-DAY OVERSIGHT ACTIVITIES

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KEY FEATURES OF OMTTM

MONITORING Track plan performance on an ongoing basis to identify operational “outliers.”  Swiftly implement corrective actions or full-scale audits in response. COMPLIANCE TOOLKIT A complete compliance toolkit designed to help organizations operating in Medicare, Medicaid, and the Health Insurance Marketplaces track the compliance of their operations. Modules developed specifically for MA and Part D sponsors address distinct operational and compliance needs. TRACK OMT™ provides the ability to track HPMS memos and other regulatory communications and the activities required to implement them. There is even a module to manage internal (and HPMS, if required) review of advertising and member materials.

AUTOMATING COMPLIANCE BRINGING A NEW LEVEL OF TRANSPARENCY TO PERFORMANCE MONITORING

Designed specifically for MA and Part D organizations by GHG subject matter experts, CaseIQ™, our latest solution, not only captures all of the data points needed to categorize, work, and report MA and Part D appeals and grievances, it also guides case processors through each case to minimize the risk of non-compliance due to user error. Plus, CaseIQ™ is a hosted solution, meaning no IT resources are required, and content and features are kept up to date by GHG.

BRINGING CLARITY TO APPEALS AND GRIEVANCES A NEW WAY TO ENSURE YOUR CASES COME TO A TIMELY AND COMPLIANT RESOLUTION

KEY FEATURES OF CASEIQTM

TECHNOLOGY Captures key information related to intake, processing, categorization, determinations, and higher appeals or re-openings to process cases according to CMS’ complex and detailed requirements. Most importantly, every case is subject to a full validation prior to closure. WORKFLOW User-friendly forms assist the case processor by automatically enabling or disabling sections according to their applicability for the current case type and entered information. COMPLIANCE Created with CMS compliance in mind, CaseIQ™ allows plan users to easily create auto-populating letter templates to generate member letters from case data.

Don’t know if CaseIQ™ is right for you? See how your solution compares:

Compliantly process MA and Part D appeals and grievances, including Independent Review Entity (IRE), Administrative Law Judge (ALJ), Medicare Appeals Council (MAC), and Judicial Review levels

Capture all CMS-required data points, as well as provider information and plan-specific categorizations for operational analysis and trending

Automatically disable, enable, or require sections based on case type and details, including Appointment of Representative (AOR)/Power of Attorney (POA), waiver of liability, good-cause exception, supporting statement, extensions, and more

Automatically calculate and update due dates and status based on CMS requirements and case information

Build a complete case file with unlimited notes and attachments directly in each record

Generate GHG-updated CMS annual reporting and audit universes at any time

Capture every single change made by a user for a complete audit trail

Perform a complete case validation ensuring all required fields are completed upon closure

Route cases to Medical Directors or other departments with automatic notification to users

Customer support provided by GHG’s in-house consultants and subject matter experts, backed by over 15 years’ experience assisting health plans with appeals and grievances compliance

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Gorman University™ provides training sessions on a variety of industry topics, each designed to meet the unique needs of your organization. Each training module has been developed and reviewed by GHG industry experts. Modules can be purchased as a set or individually.

KEY FEATURES OF GORMAN UNIVERSITYTM

ONLINE TRAINING Each self-guided course has a pre-quiz, multiple lessons with self-assessment questions, and a final exam once the course has been completed.

ROBUST REPORTING Comprehensive data lets you know when training was taken, how long it took, scores, and which questions were missed.

CONTENT-ONLY OPTION Already have your own Learning Management System? You can license Gorman University™ content to deliver alongside your training seamlessly.

SHARING KNOWLEDGE TRAINING DESIGNED SPECIFICALLY TO MEET THE REQUIREMENTS OF MA AND PART D PLANS

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The Point™ offers member-only access to the full archive of searchable GHG tools and analyses. The Point™ provides a clean and concise view of constantly updated content, delivering all the industry information you want, when you need it.

CENTRALIZING INTELLIGENCE GOOD INFORMATION DRIVES GOOD DECISIONS

Your individual or corporate membership to the Point™ gives you direct access to our consultants’ toolkit:

GHG expert summary and analysis of HPMS memos

On-demand recorded webinars

Access to the archive of GHG white papers, resources, and tools

Podcasts on timely issues

Intra-plan collaboration and sharing of best practices

Discounts on GHG events

Complimentary GHG Forum tickets

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KEY FEATURES OF THE POINTTM

EXPERT INSIGHT White papers and memos from GHG subject matter experts on everything from industry trends in delivery of care to best practices in compliance and operations. Podcasts available on the Point feature the latest developments for government-sponsored healthcare in real time.

ANALYSIS AND SUMMARY Every HPMS memo, straight from our team of Compliance experts. See which memos GHG highlights as the most critical and sort by the impacted operational areas.

ARCHIVE AND RECORDINGS Hear the latest regulatory updates, political commentary, best practices, and market analysis from the industry’s best. Listen as GHG experts discuss winning strategies in government-sponsored health programs, including MA, Part D, Medicaid, dual eligibles, and the Health Insurance Marketplaces.

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GHG created Valencia™ specifically to meet the process needs of organizations working within government-sponsored healthcare. For years, our reconciliation teams have worked within client organizations to clean member data and recover revenue. Valencia™ is our solution – it creates the workflows organizations like yours need for critical operational functions. With Valencia™, you’ll always know where your membership and premium-related data is out of sync, thus eliminating missed revenue and inappropriate claims payments.

REVOLUTIONIZE YOUR MEMBERSHIP AND FINANCIAL MANAGEMENT DON’T LET YOUR REVENUE BE HELD HOSTAGE IN MEDICARE, MEDICAID, AND THE HEALTH INSURANCE MARKETPLACES.

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CORE FUNCTIONALITY FOR OPTIMAL RECONCILIATION

DATA Cumulative view of all transactional data

COMPARISON ENGINE Weekly/Monthly comparison based on business rules

WORKFLOW TOOL Transparent, discrepancy management

SYSTEM UPDATE Generates an update back to plan system

MULTI-DEPARTMENT Supports multiple departments in their reconciliation efforts

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PaymentData

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CONTACT US!

STAY CONNECTED to industry news and gain perspective on how to navigate the

latest issues by subscribing to our weekly newsletter at https://www.gormanhealthgroup.com/subscribe and visiting our website at www.gormanhealthgroup.com.

GORMAN HEALTH GROUP is always looking for leading professionals in the healthcare industry to further enhance our team of experts. Visit us online to learn more about job opportunities, or contact us at jobs@gormanhealthgroup.com for more information.

CONTACT 5335 Wisconsin Avenue NW, Suite 340, Washington, DC 20015

Email: ghg@gormanhealthgroup.com

Phone: 202-364-8283

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GORMAN HEALTH GROUPCONSULTING AND SOFTWARE SOLUTIONS F OR MEDIC A RE , MEDIC A ID, A ND THE HE A LTH INSUR A NCE M A RK E TPL ACES

www. gormanhealthgroup.com 5335 Wisconsin Avenue NW, Suite 340, Washington, DC 20015 Ph 202-364-8283