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Toeing the line—including the bottom line.

The level of regulation in government programs, combined with new oversight introduced through health reform and federal health insurance exchanges, generates a lot of moving parts to compliance. That means increased risk and financial stake, as well as technological, operational and strategic challenges. And no matter what your plan’s Medicare and Medicaid profile was before recent changes, chances are the public sector is more prominent now in your overall strategy. While government programs can produce plenty of revenue, they also produce rules to follow. Compliance is a fact of life for health insurers and penalties are only the beginning of what’s at stake.

To safeguard revenue and efficiency as well as meet regulatory requirements, your approach to compliance can’t operate in a vacuum. You need people with experience in the same clinical and administrative disciplines you’re supporting and you need compliance to work hand in hand with your business strategy and operations.

Are your compliance efforts currently tied into your business plan? Do you have an across-the-board compliance strategy, or is it parceled out among departments? Deloitte professionals bring a broad approach to the support of your health plan compliance needs. As a result, the work you do to keep in step with regulations isn’t a distraction from your mission—it’s built in. Medicare and Medicaid operations can benefit from coordinated support across multiple areas:


  • PDE reviews
  • Risk adjustment
  • Compliance program reviews
  • Oversight and monitoring
  • Mock audits and operational evaluations
  • DIR reviews and audits
  • Sanctions testing and remediation


  • Encounter file support and governance
  • Formulary transition testing
  • Risk adjustment
  • Oversight and monitoring
  • 340b rebates
  • Reporting
  • Data validation readiness

Potential benefits include enhanced compliance program effectiveness, improved reporting and monitoring, identification and resolution of risk areas prior to audit, reduced risk of sanctions and fines, improved processes to identify and manage compliance risk and improved internal control structure to achieve business objectives.

Contact us

Tom Delegram Tom Delegram, Senior Manager, Deloitte & Touche LLP
Tom Longar Tom Longar, Senior Manager/Specialist Leader, Deloitte & Touche LLP
Jack Scott Jack Scott, Director, Deloitte & Touche LLP

As used in this document, "Deloitte" means Deloitte LLP and its subsidiaries. Please see for a detailed description of the legal structure of Deloitte LLP and its subsidiaries. Certain services may not be available to attest clients under the rules and regulations of public accounting.

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