Health Plans

Compliance is a fact of life for health insurers and penalties are only the beginning of what’s at stake. 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.

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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 while government programs can produce plenty of revenue, they also produce rules to follow.

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. Deloitte’s broad approach to compliance can help.

Our approach

​​Medicare and Medicaid operations can benefit from coordinated support across multiple areas related to compliance:


• 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

​​Our approach

Potential benefits

​​Potential benefits of a robust compliance program 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. 

Potential benefits

Meet our leaders

Tom Delegram

Tom Delegram

Managing Director | Life Sciences & Health Care

Tom is a managing director in the Business Risk practice of Deloitte & Touche LLP. He has specialized experience in regulatory compliance issues for Medicare and Medicaid health plans, prescription dr... More

Tom Longar

Tom Longar

Specialist Leader | Life Sciences & Health Care

Tom is a specialist leader in the Life Sciences & Health Care practice of Deloitte & Touche LLP. He has spent more than 20 years helping clients address complex regulatory issues. Tom advises health p... More