Payer-Side Compliance and Quality

Volumes 1 through 3 of this compendium described a compliance program's architecture, legal foundation, and core operational functions, deliberately independent of any specific payer or provider structure. Volume 4 applied that foundation to the provider side of the healthcare system. This volume completes the picture on the payer side: Medicare Advantage, Medicare Part D, Medicaid managed care, commercial and marketplace health plans, and the accreditation and quality-measurement infrastructure connecting them.

Written for compliance officers who need genuine command of payer-side regulatory frameworks and the attorneys who advise them, this volume treats each product line's compliance program requirements as its own discipline, extended across thirty chapters into the cross-cutting functions: payer-side quality infrastructure, federal obligations, program integrity, and corporate and transactional considerations that connect those product lines together.

Inside:

• Medicare Advantage compliance, marketing oversight, risk adjustment, and Star Ratings
• Medicare Part D formulary administration, coverage determinations, and PBM relationships
• Medicaid managed care compliance, actuarial soundness, and multi-state operations
• ACA marketplaces, self-funded ERISA plans, and mental health parity for payers
• 30 chapters covering FDR oversight, HEDIS, NCQA accreditation, dispute resolution, and M&A

Volume 5 is the fifth installment of the six-volume series. It completes the provider-payer picture Volume 4 began.