Understanding and implementing the Affordable Care Act and other new regulations while keeping a lid on costs and ensuring that all citizens have access to affordable, quality health care coverage is a constant challenge. Our team can help your insurance department navigate the ever-changing policy landscape with confidence.
Services Include
ACA compliance and implementation
PCG brings extensive policy expertise and operational experience to help you manage your insurance plans in compliance with the ACA. Our services start with policy development and plan review and continue through ongoing management. We are an established leader in network adequacy compliance, helping our clients ensure the review process is federally compliant and automating what has historically been a manual process.
Claims Processing Services and Solutions
PCG provides a variety of claims processing services and solutions on behalf of state agencies and payers. Working with agencies across the country, we have developed innovative and efficient operational models, as well as technological tools that we deploy on behalf of our clients to perform these important business functions at a competitive cost. By entrusting us to perform these services, our clients are able to focus on more important and strategic program functions and responsibilities. Our services include:
- Administrative Service Organization Services
- Data Intermediary Services
- Third Party Administrator Services
Contracting Oversight
As the commercial insurance marketplace continues to evolve, insurance departments are trying to identify issues in carrier-provider contracts that could be driving medical expense growth and affecting their state's ability to monitor and regulate rate increases. PCG can assist with comprehensive reviews, informed by our broader rate review work.
Consumer Protection Grant
The Affordable Care Act includes key provisions aimed at protecting consumers and eliminating discriminatory practices by health insurance plans, especially individuals with chronic and potentially costly conditions. Since 2011, PCG has developed and implemented sustainable DOI processes, checklists, data collections and review tools to support state enforcement of ACA market reforms, including Benchmark Plan coverage and Preventive services requirements; discriminatory benefit and plan design, mental health parity, network adequacy/access and consumer appeals processes.
Healthcare Access and Markets
States regulate their private insurance markets and operate Medicaid managed care and fee-for-service programs to assure healthcare access to residents. This includes access to both physical and behavioral healthcare. States turn to PCG to organize their commercial health insurance regulatory compliance.
Rate Review
The Affordable Care Act and recently proposed federal regulations require greater transparency and justification for significant rate increases as regulators endeavor to ensure both reasonable rates and sufficient capitalization of insurance plans to meet claims payment obligations. Our team’s subject matter expertise and deep understanding of state insurance department practices can help you enhance your overall rate review program and successfully meet these obligations.
Rate Setting and Support Services
PCG serves as a trusted partner to Medicaid, public health, behavioral health, and other state agencies and payers to establish payment rates for services, including setting rates for both institutional and community-based services. Furthermore, we have helped states work through other rate setting and payment related issues, such as Disproportionate Share Hospital (DSH) payments, upper payment limit calculations, and provider assessments. Not only do we help agencies establish and recalibrate rates, we also work with our clients to engage stakeholders and inform the provider community on changes to rates, in order to promote transparency and build consensus. Our services include:
- Institutional Rate Setting and Support
- Community-Based Rate Setting and Support
- Value Based Purchasing
Regulatory support services
Our legal and policy experts can guide you through changes and updates to health coverage regulations, keeping you fully informed of the latest developments and helping you understand their impact.