PCG can review your current system of care, help you better define quality and system goals, and assist in the development of compliance and outcomes measures that optimize your plan’s performance.

 

Medicaid managed care programs are intended to limit a state’s exposure to increasing medical costs while improving health and quality outcomes. However, the rapid rise of managed care has resulted in highly publicized issues with overpayments, network adequacy, and compliance of managed care plans and has given rise to increased regulations and scrutiny of managed care organizations (MCOs).

The PCG Solution

In response to heightened oversight, PCG has developed a consulting solution to help MCOs effectively monitor and optimize the delivery of managed care. Our tailored approach allows us to design a custom data collection and measurement process, payment policy approach, and outcomes measurement process to meet the unique needs of each client.

Our Expertise

PCG has worked in the Medicaid program integrity environment since the company was founded in 1986, when CEO Bill Mosakowski performed an on-site audit of a public hospital outside Boston, Massachusetts. Since that time, our efforts have grown to include a dedicated staff of more than 300 skilled and knowledgeable professionals who partner with multiple state Medicaid agencies to advance innovative approaches to program integrity and fraud and abuse.

 

PCG’s program integrity consulting and applied services include the following: a provider enrollment center, provider training modules, pre-enrollment database checks, onsite provider screening visits, prepay reviews, focused investigations, ongoing reviews, and fullscale post payment audits. We meet with provider groups to discuss new reimbursement methodologies and program regulations to promote compliance. We conduct more than 1,500 investigations each month and conduct hundreds of on-site program integrity reviews that document both compliant and non-compliant behavior.

Our Services

Compliance Consulting

New managed care standards are on the horizon and will dictate how managed care operations will change. MCOs will need expert assistance in navigating the proposed rules, which are intended to improve beneficiary communications and access, provide new program integrity tools, support state efforts to deliver higher quality care in a cost-effective way, and better align Medicaid and CHIP managed care rules and practices with other sources of health insurance coverage. PCG can assist your health plan to

  • Develop operational procedures that are in line with federal regulations and your state contracts
  • Develop adequate compliance plans
  • Improve controls to prevent overpayments
  • Adequately

Network Provider Screening, Enrollment, and Management

Properly managing the provider network enrollment process is one of the most proactive and effective ways to mitigate short-term financial losses and future network adequacy issues. PCG is one of the few provider oversight vendors in the country that conducts pre- and post-enrollment site visits of moderate- and high-risk Medicaid providers. Our service helps managed care plans identify fraudulent providers, uncover illegal provider operations, reveal noncompliant provider activity, verify or disprove a provider’s service location, and satisfy federal site visit requirements.

 

By combining program integrity efforts to combat fraud, waste, and abuse (FWA) and financial information regarding unpaid overpayments, PCG’s integrated solution identifies audited providers or individuals who owe money to the state. This allows health plans to develop strong provider networks efficiently while precisely screening out problematic providers with a history of FWA.

Pre-Payment Claims and Case File Reviews

With more than 25 years of experience helping states improve revenue cycles, PCG uses a proven approach of stopping a payment for an inappropriately billed invoice prior to payment, rather than taking the “pay-and-chase” approach. Our process incorporates a fast-turnaround clinical and technical review. We collect the required documentation from a provider for cases being billed to a managed care organization and review all documentation criteria related to the claim, as specified by the plan and as prescribed by the corresponding provider manuals.

 

Compliant claims are processed within days, while non-compliant claims are caught and returned to the front-end. Through our process, we have helped clients to achieve immediate and long-term savings from denials of unsupported claims and a statistically significant reduction in billing volume.

Post-Payment Reviews and Investigations

PCG can support the work of health plans’ Special Investigation Units (SIUs). PCG’s onsite and desk audit clinicians will conduct thorough regulatory compliance reviews, as well as a clinical review of plans of care and progress notes. PCG can manage the response and audit of recipient and community complaints regarding providers requiring review. By proactively identifying and analyzing outlier provider patterns, our prior-year audits are proven to produce real recoupment results. We will work with health plan clients to develop an audit report standard that fully supports our recoupment findings and that meets specific contract stipulations.

 

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Download the Medicaid Managed Care Oversight Consulting Services For Managed Care Organizations 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 Medicaid Managed Care Oversight Consulting Services For Managed Care Organizations please contact us at info@publicconsultinggroup.com or 1-800-210-6113.