Medicare Solutions
A partnership with TMG Health allows health plans and PBM's to focus internal resources on member outcomes and other crucial success factors in today's competitive Medicare market
4.3M
members served
annually
14M
claims processed
annually
3.5M
member & provider calls
per year
As the premier provider of solutions for health plans and Pharmacy Benefit Managers (PBMs) in the Medicare Advantage, MAPD and Medicare Part D markets, TMG Health offers end-to-end strategic sourcing and component solutions which are designed to keep pace with the changing needs of the government healthcare market.
Our Medicare solutions enable payers to:
- Manage Growth
- Control Costs
- Meet Strict Compliance & MLR Requirements
- Skillfully Manage Enrollment, Claims & Customer Service Processes
- Skillfully Manage processes for the Complex Dual Eligible Population
We provide:
- Rapid Implementation & On‑Boarding
- Process Transparency
- Data Security with Fully‑Redundant Network Capabilities & 2 Tier IV Data Centers
- Project Management
Our empirical experience, best-in-class technology and subject matter expertise enable us to deliver superior results for your critical services, including:
- Enrollment, Eligibility Management and Reconciliation (CMS & Medicaid)
- Premium Billing
- Claims & Encounter Processing
- Member/Provider Call Services
- CMS and State Reporting
- Financial and Capitation Reconciliation
- Print Fulfillment
- Compliance Tracking & Assistance
- Medical Management
Compliance Assurance
CMS Star Ratings determine reimbursement rates and can ultimately determine the profitability of a Medicare Advantage program. Health plans need an experienced partner who knows how to navigate the rapidly-evolving regulatory environment. At TMG Health, our solutions are “wrapped in compliance.” Our independent Compliance and Audit Services Department utilizes insight gained from supporting CMS health plan audits and state readiness reviews for multiple health plans in multiple states to support your team.
Our Compliance experts provide oversight and monitoring in our operational areas, internal systems configuration, processes and documentation. We also employ an Internal Audit staff and are fully compliant with SSAE 16 standards.
Our expert Medicare solutions include a host of compliance services, including:
- Tracking of CMS Guidance and Transmittals
- Proactive Monitoring of State Medicaid Contracts and Communications
- Monitoring & Identification of Risk
- Fraud, Waste & Abuse Prevention and Detection
- Federal (CMS) and State Audit Support (Internal, External, Client Delegation)
- CMS User Group Calls
- Annual Election Period Preparation Assistance
TMG Health is a member of the National Health Care Anti-Fraud Association (NHCAA)
Medicare Solutions
To thrive in the Medicare market, you need to focus your efforts on improving member care and outcomes as well as compliance with CMS…
Solutions Overview
TMG Health is the leading national provider of Business Process Outsourcing services for Medicare Advantage, Medicare Part D and…
Capabilities Portfolio
Information Technology Business Intelligence • Compliance • Membership Processing • Claims Administration • Member & Provider Services…