Did You Know?
Did you know your site visit program could be managed externally and fully funded at no cost to the state? Keeping a pulse on providers is vital, yet challenging for many states. A lack of time, personnel, and adequate resources are common barriers in the development of a comprehensive site visit program for Medicaid providers. PCG has conducted over 10,000 Medicaid provider site visits to proactively verify provider qualifications and protect public agencies and taxpayers from fraud, waste, and abuse by unscrupulous providers. More than 50 percent of unscheduled site visits result in noncompliance findings.
The Traditional Pay and Chase Approach Doesn’t Work
The traditional "pay and chase" approach to provider audits entails waiting for high risk providers to enroll and bill Medicaid, often at high rates, before scrutinizing them. Even the most thorough audit may only recover pennies on the dollar. PCG Health is one of the few provider oversight vendors in the country that conducts pre and post-enrollment provider site screenings that can save your state hundreds of thousands of Medicaid dollars. One year of PCG provider site screenings yielded one state client a projected cost avoidance of greater than $30 million.
PCG Site Screening Process
PCG conducts pre and post-enrollment site visits for moderate and high-risk provider types to ensure your Medicaid agency only enrolls and has enrolled credible, qualified providers who deliver services and meet Medicaid requirements. Our team develops and manages the program based on your state's needs and regulations, while using industry-leading technology to ensure consistency, efficiency, and robust reporting capabilities.
What do we find?
Our screening professionals discover empty warehouses, illegal adult day care operations, fraudulent billing practices, providers with limited understanding of Medicaid policy, and companies with non-credentialed staff members who are actively billing Medicaid. In our experience, if you are not conducting site screenings for your moderate and high-risk provider types, you are paying the price in fraud, waste, and abuse.
We know Medicaid.
PCG is a national leader in state agency health care consulting with 28 years of experience in the field. Our current clients include 36 state Medicaid agencies and our staff includes former Medicaid agency professionals with vast knowledge of Centers for Medicare & Medicaid Services (CMS) and state Medicaid policy and regulations.
Compliance reviews ascertain whether providers are billing appropriately.
In addition to confirming that providers are billing a client organization in compliance with that agencies regulation, a review ensures that providers have the appropriate underlying financial records to support their claims. Beginning in 2010, PCG has been conducting annual claims reviews of hospitals and community health centers for the Commonwealth of Massachusetts Division of Health Care Finance and Policy, Health Safety Net. The average amount of funds recouped by the Commonwealth as a result of PCG reviews is $500,000 annually.