New Government Program Opportunities

Entering into a new government program whether it is Medicare Advantage, Part D, Medicaid, Dual Eligibles, or a version of any of them, can be an intimidating and overwhelming experience for any company. ClearStone Solutions’ industry experts have years of experience guiding organizations through the millions of steps it takes to enter a new market or develop a new program successfully, mitigating the risk of compliance errors while reducing the amount of time it takes to be up and running by as much as 6 months.

Market Assessment

ClearStone Solutions has completed successful market assessments for various types of organizations, including Health Plans and Area Agencies on Aging.

Market Assessments Include:

  • Analyses of market influences
  • Customer demographics
  • Market position and product mix
  • Current competitors
  • Market sector trends
  • Pricing and opportunities analysis
  • Financial modelingj
Strategic & Business Planning

ClearStone Solutions assists the Health Plan in defining the company’s goals in relation to their government program opportunities. We develop plans and to take advantage of those opportunities while meeting financial and growth objectives.

Services include:

  • Mission Statement development
  • Analysis of current plan attributes
  • Identification of potential threats and opportunities
  • Creation of a vision for the future
  • Definitive goals, strategies and tactics
Product Design

ClearStone works with clients to develop successful products such as:

  • Benefit design
  • Actuarial consultation
  • Financial optimization for Medicare Part C and/or Part D, Medicaid and Dual Eligible products.

ClearStone has special expertise in integration of waivers for dual eligible products.

Actuarial Support

Medicare, Medicaid and Dual Eligible plan bid development support, prospective product financial feasibility analysis, and benefit analysis.

Application Management

Complete management of state Request for Proposal response documents and/or CMS Part D and Medicare Advantage applications, including Special Needs Plans (SNPs) and CMS Demonstration Projects for new contracts and service area expansions, including development support, project management and document submission and managing the process to acceptance.

Health Plan Readiness

Knowing when a Health Plan is ready to create and operate a compliant and effective government program is a critical step. ClearStone completes audits of the Health Plan to determine such functional readiness and identifies when a plan is able to or needs to do in order to operate a compliant and effective program.

Readiness reviews include:

  • Operations readiness in terms of system functionality
  • Process preparedness
  • Policy and procedure adequacy
  • Overall compliance with contractual and regulatory requirements
Staffing Assessment

ClearStone can provide thorough assessment of current staffing levels with recommendations to optimize efficiencies for various operations and administrative areas of government programs.

Additional support available:

  • Committee charters and implementation
  • Job description development
  • Regulatory requirements for staff screenings and related areas
Operations Assessment & Development

ClearStone Solutions offers critical advantages in the assessment of plan operations through our subject matter experts who are familiar with all disciplines of government programs and have a deep appreciation for the interrelationship of the operational functions. This familiarity or “Health Plan view” provides a keen understanding of the downstream and cross-functional impacts of operational changes.
Our team provides analysis, development and management support for all operations areas including enrollment, billing, membership, service, appeals and grievances, claims processing, network, pharmacy benefit manager services, compliance, finance, plan administration and others.

Services include:

  • Gap Analysis against regulatory and contractual obligations
  • Best practice consulting
  • Insourcing and outsourcing options
  • Work plan development for implementation of required changes
  • Readiness review
  • Option analysis with recommendations
Vendor Selection & Management

ClearStone has extensive knowledge in the vendors available in the government programs market. We provide assessments with recommendations for every touch point with vendors.

Assessments available:

  • Operational component retention and outsourcing
  • Vendor selection
  • Vendor request for information/proposal development and process management
  • Vendor integration into Health Plan operations
  • Vendor oversight program requirements
  • Vendor performance monitoring tools
  • Best practices for the Health Plan
Operations Platform / Systems Analysis

ClearStone can provide analyses of operations systems for compliance, capacity/capability, and recommendations for performance optimization.

Examples of system reviews include:

  • Claims systems evaluations for system ability in Medicare, Medicaid and Dual Eligible program claims pricing
  • Accurate adjudication (including benefit set-up attributes with ability to handle integrated programs)
  • Capture of required reporting fields with system upgrade and our outsourcing recommendations.
  • Enrollment system reviews including capability to capture Medicare/Medicaid required fields
  • Automated document transmittal triggers
  • Reporting element capture
  • LIS, LEP and billing.
Compliance Program Development

ClearStone Solutions can provide Health Plans entering into Government programs with complete services for support of the implementation of compliance program that fully incorporates the required seven elements.

Services include:

  • Development of compliance program structure with roles and responsibilities
  • Policies and procedures
  • Standards of conduct
  • Compliance
  • FWA training and education
  • Staffing recommendations and job descriptions
  • Regulatory guidance monitoring and implementation tracking processes
  • Audit preparedness exercises
Operation and Administration Policy & Procedure Services

ClearStone Solutions possesses a vast library of tried and true policies and procedures that can be customized to fit Health Plans operations. ClearStone Solutions subject matter experts are also available to review existing policies and procedures for compliance with current regulatory requirements.

Product Launch & Training Programs

ClearStone Solutions can manage the process for launching a new Government Program product/program and ensure staff and vendors are trained and ready.

Training areas include:

  • Overall compliance
  • FWA
  • Customized training specific to each plan operations function
Program Implementation

ClearStone Solutions has staff experienced with new plan implantation and with operations transitions projects for Medicare, Medicaid and Dual Eligible programs. ClearStone Solutions can provide project planning and project management support, as well as specific area review and testing, which will ensure that linkages are made between associated cross-functional and downstream areas, using a holistic “Health Plan view” of the entire scope of operations.

Model of Care Development

ClearStone Solutions will assist the Health Plan in developing a model of care that includes:

  • Concentration on simplifying access for high risk members; improving service delivery through coordination of care through an identified point of contact, seamless transitions of care across healthcare settings, providers, and health services, and encouraging a holistic, patient-centered, approach to health care
  • Use of Health Risk Assessment (HRA) data to identify members throughout the year who would benefit from additional case management
  • Identification and development of roles of Acute Care Managers
  • Utilization management, disease management, and care/case management programs
  • Palliative care models
  • Patient education
  • Care setting transition programs
  • Medication therapy and pharma therapy programs and oversight
Medicare / Medicaid Integration
Existing Government Program Operations

Many organizations enter into government program operations under the assumption they can add it onto their existing operating platforms and using their existing operational expertise. But operating a government health plan is different. The risks of doing it wrong are high and operations come under the scrutiny of state and federal regulators. ClearStone Solutions consults with organizations already operating a government program to improve compliance and quality, decrease costs, and ultimately improve their revenues.

Operations & Quality Metrics

ClearStone can perform gap analyses to determine core issue(s) behind not meeting operations and quality metrics. Our goal is to re-establish realistic and/or required operations, quality metrics and assistance with implementation of outgoing monitoring programs to create an environment for sustained success.

Financial Metrics

ClearStone can provide assessments and recommendations for appropriate financial metrics. We perform gap analyses to determine what core issues underlying which are not meeting financial metrics.

Policies & Procedures

ClearStone’s services can include assessment of existing policies and procedures for compliance with CMS and/or state requirements. ClearStone has a vast library of tried and true policies and procedures that can be customized to fit the Health Plan’s operations. ClearStone can support your policy and procedures needs overall or for specific plan areas.

Vendor Selection & Management

Selecting and managing vendors which support government program is complex and difficult. ClearStone Solutions with its extensive knowledge can guide plans through these difficult tasks.

Services Include:

  • Request for Proposal (RFP) development
  • RFP response evaluation
  • Contract development and negotiations support
  • Pre-delegation audits
  • Development/refinement of vendor oversight programs and monitoring protocols
  • New vendor integration into Health Plan operations
  • Vendor transition planning and management
  • Vendor performance issue resolution process implementation
Reconciliation Services
  • PDE: Pharmacy Drug Event
  • Membership/New Enrollment: Ensure government programs membership aligns with what membership the state or CMS has documented.
  • Billing/Premium Collection: Reconcile billings against money collected.
  • Financial/Risk Adjustment (RAF): reconcile actual payment with expected payment, monitor financial impact of applying RAF scores.
Systems Assessments (Claims, Enrollment)

ClearStone can provide assessments of existing systems to determine and resolve issues. Claims system reviews target problems associated with accurate payment of Medicare, Medicaid, or Dual Eligible claims. Enrollment systems reviews examine accuracy of automated updates, capabilities for new product support (such as a system supporting Medicaid where the Plan wishes to implement a Medicare Advantage/Medicaid Special Needs Plan).

Compliance Program Services

ClearStone Solutions can provide examination of current processes and documentation used to support the existing compliance program for conformity with current requirements, assistance with implementation of program enhancements, targeted process support.

CMS / State Audit Readiness

ClearStone Solutions can ensure that a Health Plan is ready for an audit, a critical part of a plan’s success in government programs.

Services Include:

  • Review of Plan’s state of readiness for state/CMS auditors
  • Assistance with resolution of issue areas
  • Mock audits
  • Audit interview preparatory coaching
  • Audit project management
  • Post audit findings response support
Marketing Strategies & Tactics

ClearStone with their vast industry knowledge can identify and create marketing strategies that position a Health Plan for success. ClearStone can assess current strategies and tactics for boosting membership retention, loyalty, and new member enrollment, create new strategies for improved communications and increased marketing ROI. ClearStone also has a vast library of tried and true, compliant member and marketing materials which can be leveraged to supplement existing materials or to replace those that are non-compliant.

Staff Optimization

Knowing how to get the most out of a plan’s staff is critical to success in government programs. ClearStone Solutions can provide assessments of existing roles and responsibilities with recommendations for staffing changes to meet financial and growth goals.

Services Include:

  • Consultation on candidate requirements
  • Job descriptions
  • Organizational reporting structure for government programs staff
Medical Management Programs

ClearStone can provide consultation and advice on how to create and/or optimize medical management programs.

Services Include:

  • Review of model of care
  • Policies and procedures for Utilization Management
  • Disease Management
  • Case Management
  • Clinical pharmacy management
  • Behavorial health
  • Prevention and wellness programs
  • Reporting processes and oversight
  • Health information analytics
  • Quality programs
  • Palliative care
  • Discharge planning against state and federal regulations
program administration
Government Program Management

ClearStone Solutions can be your “Government Program in a Box”. Outsource your entire operation to ClearStone Solutions, with the exception of required plan retained functions such as Compliance Officer or areas such as Sales and Network Management. This allows you to maintain areas that help the plan maintain the local “flavor”. You can also choose discrete areas to outsource, such as membership, service or claims administration, retaining only those areas which are strategically appropriate. Selecting ClearStone Solutions Services, you gain economies of scale and the ability to redeploy your key staff to optimize internal program functions.

Leveraging relationships with best in class operations organizations to perform transactional services, ClearStone adds:

Scalable Operating Structure

Because ClearStone Solutions currently operates existing government programs, even a Health Plan with low enrollment can take advantage of the reduced operating costs and increased rebates available to larger Health Plans.

Simplified Oversight

ClearStone Solutions shoulders responsibility for day to day operations management, monitoring and performance oversight, allowing the plan to direct all questions, concerns and requests to a single source, eliminating the need for a large contingent of personnel dedicated to scrutinizing plan operations.

Implementation Management

ClearStone Solutions staff’s involvement with implementations and ongoing operations gives them a deep understanding of the criticality of various facets of system operation, and also, the options available for ensuring functionality at time of plan launch. Plans are provided with regular status updates and encouraged to participate in business requirements development.

Operations Monitoring & Oversight

ClearStone Solutions uses a fully developed oversight program to supervise operational performance. This program includes ongoing communications, review of required reporting and sample auditing of critical areas against regulatory and contractual requirements. Results of the program are provided to our Health Plan clients on a regular basis to keep them informed of the status of their program administration.

Policy & Procedure Development, Implementation & Ongoing Adherence

ClearStone Solutions will develop and implement compliant policies and procedures, customized to the unique characteristics of your Health Plan. Operations monitoring will include testing for ongoing adherence to the policies of your plan.

Reporting Metrics

ClearStone Solutions will provide regular operations and executive level reporting to your plan to support your oversight of the program. Reports can be customized to provide information on those areas most important to you.

Compliance Support

Although the Compliance Officer is required to be part of your Health Plan staff, ClearStone Solutions can provide the support staff and processes to operate your compliance program. ClearStone Solutions has processes in place that create an environment of continuous regulatory compliance, with regular reporting which relate the status of compliance program activities and findings.

Regulatory Monitoring & Implementation

ClearStone Solutions has best in class processes for identification of regulatory changes which impact program operations. These processes follow new or altered requirements from development and implementation of new business requirements through testing and auditing to ensure they are successfully incorporated into program operations.

Reporting to CMS / State

The reporting requirements of CMS and state Medicaid agencies are sometimes difficult to interpret and implement correctly. ClearStone Solutions has staff experienced in the development and implementation of business reporting requirements that accurately reflect the nuances of government required reports. ClearStone’s staff is also experienced and skilled in CMS required Data Validation audits and relieve the Health Plan from all duties associated with such audits except for review of those measures for which the plan has retained some duties.

Support for CMS Filing
Billing Oversight

Monthly review of member premium billing for correct application of LIS and LEP amounts and payments.

Invoice Reconciliation

Review and reconciliation of vendor invoices to assure billings are appropriate to services rendered.

Staff & Vendor Training

In addition to compliance and fraud, waste and abuse (FWA) training programs, ClearStone Solutions staff creates and implements training programs specific to operational functions in order to ensure that staff performing these tasks have a well-developed understanding of the correct and compliant methods to be used in carrying out their responsibilities.

Compliance Support Management

Although not the only concern in Government Program Operations, but certainly in the top three, the word compliance can make the strongest health plan executive nervous. ClearStone solutions has years of experience amongst its subject matter experts developing compliance programs, identifying risk areas, quickly putting action plans together, preparing health plan executives to communicate with regulators, and overall mitigating the risk of penalties, fines and sanctions. With ClearStone Solutions, you can achieve peace of mind.

Internal Audits

Sponsors must establish and implement an effective system for routine monitoring and identification of compliance risks. The system should include internal monitoring and audits and, as appropriate, external audits, to evaluate the sponsor’s, including First Tier, Downstream and Related Entities (FDR), compliance with CMS and/or state Medicaid requirements and the overall effectiveness of the compliance program. ClearStone Solutions performs annual audits of all downstream vendors against regulatory requirements.

Pre-delegation Audits

Health Plan Sponsors have the right to delegate certain business functions and responsibilities to contracted vendors or related entities. CMS requires that the Health Plan perform a review to ensure that those vendors/entities meet the CMS compliance standards. In addition to being a requirement, this pre-delegation audit is a good practice as CMS, holds the Health Plan sponsor accountable for any vendor non-compliance. ClearStone Solutions conducts an audit of the vendor/entity prior to delegation to ensure compliance standards are met.

Policy & Procedure Audit & Refinement

Evaluation of existing policies and procedures against a complete list of policies and procedures required by CMS and the State, as well as current regulatory guidance. Utilizing its experience and vast library of CMS and State approved Policies and Procedures, ClearStone Solutions will refine and/or supplement the Health Plan Sponsors’ existing policies and procedures to meet CMS or state requirements.
Marketing Materials Review: ClearStone Solutions will create all applicable CMS required member letters/materials using Health Plan letterhead. ClearStone Solutions will also implement a process to manage and submit materials to CMS and the State for review and approval, for those materials requiring submittal.

Fraud, Waste, and Abuse (FWA) Plan Development & Training

FWA prevention, detection and investigation is an area of great emphasis for federal and state government agencies in the health care arena. Implementation of sound practices in this area is key to maintaining regulator confidence. In addition, the Sponsor’s employees (including temporary workers and volunteers), governing body members, and those of any FDRs who have involvement in the administration or delivery of Medicare Part C and/or D benefits must, at a minimum, receive FWA training within 90 days of initial hiring (or contracting in the case of FDRs), and at least annually thereafter. Additional, specialized or refresher training may be provided on issues posing FWA risks based on the individual’s job function (e.g., pharmacist, statistician, customer service, etc.). ClearStone Solutions understands these requirements and works with Sponsors to implement processes and training programs that are appropriate for the Health Plan and compliant with regulatory requirements.

Quality Program Monitoring

All Medicare Advantage Organizations (MAOs) are required to have a Quality improvement Program (QIP). MAOs must conduct QIPs that measure and demonstrate improvement in health outcomes and beneficiary satisfaction and a include a Chronic Care Improvement Plan (CCIP) for at least one chronic condition. ClearStone Solutions will develop and manage a QIP that includes systematic collection, analysis, and reporting of quality performance data as described in 42 CFR §422.516(a) and §423.514 for Medicare Parts C and D, respectively.

Corrective Action Plan Oversight & Management

ClearStone Solutions has proven processes for overseeing the development, implementation, and status monitoring of corrective action plans for Health Plan and vendor operations. These processes include post-implementation monitoring to ensure that changes made create and maintain compliance.

CMS Audit Preparation

ClearStone Solutions has developed a rigorous program for preparing Health Plans for CMS and/or State audits. The program includes “mock audit” documentation and process reviews, as well as staff coaching to prepare Health Plan representatives to appropriately answer questions, all of which minimize the risk of corrective action.
Attestation Management: CMS requires that Health Plan Sponsor Senior Leadership affirm that reporting/statements made related to certain elements of program operation be accurate, complete and truthful. ClearStone Solutions has procedures which provide documentation of the evaluation of elements subject to the attestation in order to assure that executives signing the attestations can do so with confidence or, in cases where issues are identified, can provide qualified attestations, where necessary.

Call Letter and HPMS Memo Review & Organizational Impact

CMS issues an annual Call Letter which communicates new rules, rule changes, and/or changes to rule interpretation. CMS also provides interim guidance changes via HPMS Memos which are issued on a continual basis throughout the year. ClearStone Solutions utilizes its vast experience to interpret these communications and institute necessary changes to the Health Plan Sponsor’s end-to-end operations in order to ensure continued compliance.

Vendor Management Services

Health plans can choose to outsource the oversight and operational management of their contracted vendors to ClearStone, who will integrate the suite of vendors into one streamlined operation. Some examples of commonly outsourced operational areas include:


Pharmacy Benefit Manager

Pre-sales Call Center

Vendor that takes calls and makes outbound calls, as allowed, to prospective Medicare Advantage enrollees.


Vendor that collates, stores, and sends marketing and/or member materials to prospective or current enrollees.

Medical Management

Behavioral health, health risk assessments, case management, etc.

Transactional Services

Enrollment processing, membership, service, claims processing, etc.

Identification & Selection of Best in Class Vendors

If the Health Plan sponsor does not have a current vendor or would like to consider alternative vendors, ClearStone Solutions will assist the Health Plan with the development, issuance and evaluation of responses to requests for proposal to ensure selection of the best vendors,

Vendor Contracting & Negotiations

ClearStone Solutions will conduct all vendor negotiations and contracting on behalf of the Health Plan.

Pre-delegation Audits

Prior to outsourcing or delegating functions to vendors, ClearStone Solutions will audit the vendor to ensure operational readiness and compliance.

Integration of Multiple Vendor Systems

ClearStone Solutions can develop a plan to integrate multiple vendors and their systems into one streamlined operation.

Vendor Contract Oversight

ClearStone Solutions uses ongoing monitoring and auditing practices to ensure that vendors are meeting their contractual obligations.

Compliance & Quality Oversight

ClearStone Solutions monitors vendor adherence to compliance and quality standards and institutes corrective action plans, where necessary.

Vendor Relationship Management

ClearStone Solutions’ staff maintains ongoing communications with those of the vendor(s) in order to foster an open dialog which promotes good relations.