Our Services

Health Plans & TPAs

Health Plans and Third-Party Administrators (TPAs) face many challenges from controlling costs, developing competitive products, providing efficient and cost-effective service, and offering affordable insurance to the members they serve. There are constant pressures to minimize costs yet remain market competitive to employers and members.

Rivet Health Law assists Health Plans and TPAs to manage costs while remaining compliant with contract requirements specific to auditing, monitoring, fraud, waste, and abuse (FWA), and claims processing. The founding attorney of Rivet Health Law is steeped in experience formally building and creating FWA infrastructure and SIU units.

Our Health Plan and TPA practice includes:

• Developing Fraud, Waste and Abuse Manual
• Reimbursement, pricing, and billing matters
• Statutory and Regulatory analysis
• Auditing
  • Medicare Program Audits
  • Risk Adjustment Data Validation Audits
  • Medicaid Audits
  • Commercial Audits
• Develop FWA / SIU structure
• Develop and Review Policies
• Claims Data Analytics
• Development of Claims Edits
• Administering Contract Compliance Requirements specific to:
  • Auditing
  • Monitoring
  • Claims Audits
  • Government Reporting Requirements
• Reviewing and providing Appeals Determination
• Assisting Contracting with Reimbursement and Claims matters
• Assisting Provider Relations with Provider Education and drafting Communications