Health Consulting Services
The Health Consulting team serves as a trusted partner to state and federal regulators experienced in managing audits, examinations, and investigations across a wide range of health insurance programs and benefits. With a team of seasoned professionals, the Health Consulting team brings deep regulatory knowledge and technical expertise to support compliance with federal and state laws and reform.
Our multidisciplinary team includes regulatory attorneys, policy analysts, clinicians, pharmacists, claims auditors, and benefit design experts. We use plan documents, rate filings, claims data, internal policy reviews, and CMS review tools to conduct thorough and defensible compliance assessments in the following areas:
Affordable Care Act (ACA) Compliance
Our ACA compliance reviews help regulators ensure that health plans meet federal and state requirements designed to protect consumers and promote fair access to care.
Key Areas of ACA Expertise
Health Market Conduct Examinations
Essential Health Benefits (EHB)
Preventive Services
Cost-Sharing Limits
Guaranteed Availability & Renewability
Rating & Underwriting Practices
Qualified Health Plan (QHP) Standards
Transparency & Consumer Protections
Clinical & Network Reviews
Training & Technical Assistance
Health Policy Research
Mental Health Parity and Addiction Equity Act (MHPAEA) Compliance
Our MHPAEA compliance reviews help regulators ensure that mental health and substance use disorder benefits are offered on par with medical/surgical benefits.
Key Areas of MHPAEA Expertise
Quantitative Treatment Limitations (QTLs)
Non-Quantitative Treatment Limitations (NQTLs)
Benefit Classification Mapping
Comparative Analysis Documentation
Pharmacy & Clinical Reviews
No Surprises Act (NSA) Compliance
Our Health Consulting team provides specialized regulatory support to state and federal agencies in enforcing the No Surprises Act (NSA), a critical consumer protection law aimed at eliminating surprise medical billing and promoting transparency in healthcare pricing.
Key Areas of NSA Enforcement Expertise
Qualifying Payment Amount (QPA) Audits
Overlap with State Balance Billing Laws
Claims & Billing Practices
Disclosure & Requirements
Data & Documentation Review
Transparency in Coverage (TiC) Compliance
Our Health Consulting team provides specialized support enforcing the federal Transparency in Coverage (TiC) rule, which mandates that health insurers and group health plans disclose cost-sharing information and negotiated rates to promote consumer awareness and market accountability.
Key Areas of TiC Compliance Expertise
Machine-Readable Files (MRFs)
Cost-Sharing Disclosure Tools
Claims Payment Policies & Methodologies
Data Integrity & Accessibility
Prescription Drug Formulary Review Services
Our Health Consulting team provides specialized regulatory support in conducting comprehensive and targeted reviews of prescription drug formularies to ensure compliance with federal and state health insurance laws.
Key Areas of Focus Specific to Formularies
Essential Health Benefits (EHB)
Compliance
Mental Health Parity and Addiction Equity Act (MHPAEA)
Clinical Appropriateness & Access
Transparency & Consumer Protections
Pharmacy Benefit Manager (PBM)
Oversight
Team Leadership
Christine Thomas, MCM
Senior Managing Director
Mitchell Ristine, JD, CIE, FAHM, MCM
Senior Director and In-House Counsel
Melinda Domzalski-Hansen, MCM, AIE, PAHM
Director
Cynthia M. Fitzgerald, AIRC, ACS, AIAA, CICSR, CFE(Fraud), CIE, MCM, PHAM, ITP, CCP
Director
Caroline Bergh, CIE, FAHM, MCM
Director
Chris Cagle, JD, CIE, MCM
Assistant Director
Rebecca Palasek, CIE, FAHM, FHIAS, HCP, MCM, MHP
Senior Manager
TESTIMONIALS
What our team says about us
Cynthia M. Fitzgerald, AIRC, ACS, AIAA, CICSR, CFE(Fraud), CIE, MCM, PHAM, ITP, CCP
Director
Working at ER has allowed me to develop my leadership skills to elevate my team in the Health Consulting Services space. Consistent and meaningful engagement with executive leadership at ER is incredibly supportive and collaborative. At ER, we foster a creative work environment where everyone feels valued and heard. ER leadership is committed to professional development and work life balance. I enjoy the opportunity to lead a strong team with vision and purpose as we support state and federal regulators with dynamic and creative solutions. One of the attributes I like most about working at ER is the opportunity to work closely with other leaders in other areas of insurance regulation. This opportunity is only possible when leaders feel trusted, supported and equipped with the tools necessary to be successful. At ER, we take care of our clients, our team and each other as we deliver on our mission.
Craig Leonard, CIE, CPCU, CCP, FLMI, ARC, AIAF, ARM, MCM
Senior Director Market Conduct
Working at ER has been an incredible experience that allows me to lean into my strongest skills as a thought leader who is always looking to raise the bar and find better ways to improve market regulation processes. ER’s commitment to quality, efficiency, and first-rate representation creates an environment where innovation thrives, and continuous improvement is the standard. Our firm’s streamlined structure ensures prompt attention to clients at all levels, enabling me to partner with them in meaningful ways and consistently exceed their expectations. In my 34 years being involved in market regulation, I have never worked with a more knowledgeable, dedicated team. With deep knowledge and dedication to the NAIC’s Market Regulation Handbook, combined with our ‘out-of-the-box’ thinking, we identify critical findings often overlooked by others. I take immense pride in the work we do and the value we provide to our clients every day.
Mark Ossi, CPA, CFE, AMCM, CFE (Fraud)
Director Financial Analysis
In my previous position as a state regulator, ER was one of our trusted contracting firms. I felt like they were a strategic partner in the Department’s insurance regulatory oversight and was happy to have them be part of our team for the seventeen years I was employed at the Georgia Department. In 2019, I joined the ER Team and have been even more impressed with ER’s professionalism, culture and commitment to assisting our client’s mission of regulatory oversight of the insurance industry with the goal of safeguarding policyholders.
We'd love to hear from you! Share what services you are interested in and how we can work together to achieve your goals.
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CORPORATE HEADQUARTERS
20 10th Street NW, Suite 803
Atlanta, GA 30309-6197
Office: 404.816.6188
Fax: 404.816.6197
UTAH OFFICE
10619 S. Jordan Gateway, Suite 335
South Jordan, UT 84095
Office: 801.562.5748
VIRGINIA OFFICE
145 N. Main Street
Stuart, VA 24171
Office: 276.694.3806
Fax: 404.816.6197