In a challenging economy, every dollar counts. Don't let waste, fraud, and abuse hinder your state's Medicaid programs. Public Consulting Group (PCG) can provide a significant cost avoidance measure to your state and ensure Medicaid provider compliance by implementing a prepayment audit process.

From Institutions to Community Settings

The Supreme Court ruled in Olmstead v. L.C. (1999) that states are required to provide individuals with disabilities with community-based alternatives to institutional services. This decision, supported in 2001 by the New Freedom Initiative, sparked serious discussion about the delivery of mental/behavioral health services and added to the evidence showing that placing and treating individuals in a community setting provides significant cost savings over institutionalization. As state legislatures grapple with ever-increasing budget deficits, many are looking to provide community-based behavioral services in order to cut costs, while avoiding the elimination of these services altogether.

 

Despite gains in savings, community-based services pose oversight issues due to subjective evaluative criteria, as well as the push to decentralize the administration of services. To address this, state governments have adopted a significant number of measures designed to address waste, fraud, and abuse in their Medicaid programs, but elements of waste, fraud and abuse continue to grow.

PCG Solution Combats Waste, Fraud, and Abuse

PCG can implement pre-payment reviews that will decrease problematic providers, help your state realize significant savings due to preventative cost avoidance, and ensure compliance in current Medicaid providers.

Process Design

The PCG team uses its networking experience and resources to design a process that streamlines communications and provides for a seamless flow of information between all parties.

Policy Advisory

PCG provides trained clinical reviewers who are highly knowledgeable about behavioral health/medical policies and the clinical audit process.

Document Management

PCG operates a secure online file transfer protocol that allows providers to upload all documentation required for the audit process. We maintain all documents in a highly secure document management system.

System Design

PCG's custom-built, HIPAA-compliant application is uniquely designed to support the prepayment review process. Automated processes efficiently capture Medicaid claims data available online and perform audits on quantitative requirements. Clinical reviewers can access the online clinical review tool and central documentation/data clearinghouse to assess claim and patient information, as well as all supporting documentation, to perform audits on qualitative requirements. The system also provides a Web portal that allows for provider feedback on non-compliant claims and missing documentation.

System Support/Training

PCG meets with every Medicaid provider that is new to the pre-payment process and provides the initial instruction and training required to integrate that provider's documentation and claims into the pre-payment review process. Providers receive continual feedback regarding the process and any changes in clinical review requirements. PCG also provides support to providers on improving compliance.

Analysis and Reporting

PCG's software is capable of tracking outcomes on all review items and can use that information to produce a customized suite of reports that will provide outputs on all claims that have been reviewed, reasons for failed claims, and overall trends in claim compliance.

Benefits

PCG's proven behavioral health prepayment review solution offers clients several benefits, including

  • quick and easy access to needed information from PCG's centralized web-based application;
  • improved communication among all parties;
  • significant preventative cost avoidance due to a decrease in claims submitted from problematic providers;
  • a decrease in backlog of claims, which results in timely payment for accepted claims.

 

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Download the Prepayment Review Services Datasheet

If you would like a printable copy of this information please download our datasheet.

 

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More Information

For more information about PCG Health's Prepayment Review Services please contact us at
info@publicconsultinggroup.com or 1-800-210-6113.