Through our comprehensive array of services, we 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 managed care in your state.

 

Medicaid managed care programs are intended to limit a state’s exposure to increasing medical costs while improving health and quality outcomes, but the rapid rise of managed care has also introduced challenges and risks. While managed care organizations (MCOs) are expected to be self-reliant and self-compliant, states are increasingly finding issues with network adequacy, duplication of services and payments, and other program integrity issues. These are largely the result of gaps in data validation, lack of internal MCO controls, inconsistent program integrity practices across fee-for-service and managed care, ineffective contracts with MCOs, and improper performance tracking.

The PCG Solution

PCG has developed a consulting solution to help states 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 state 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 experts partnering with multiple 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 full-scale 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.

 

 

Prevent the Cycle of Managed Care Overpayments

Plan Monitoring and Policy Development

Although Medicaid managed care programs provide greater control and predictability over Medicaid spending, states have a unique incentive to monitor inappropriate payments made by MCOs. The per-person rate a state pays is based in part on how much spending MCOs report. Because overpayments by the organizations inflate those figures, they put the state at risk of paying unnecessarily high premium rates in the future.


We can conduct independent reviews of encounter data to ensure health plans perform adequate checks for inappropriate charges. We can also help evaluate internal financial controls and compliance programs to determine whether they align with contractual and regulatory requirements. Of particular importance is ensuring that MCOs

  • Improve controls to prevent overpayments
  • Adequately report identified overpayments and cost recoveries

Contract Development Assistance

Requirements for managed care vary from state to state, and contracts are at the center of plan management. States should adhere to best practices in program integrity requirements and incentives so that these measures can be implemented directly into these documents. We can help determine which solutions are best suited for your state. Our vast experience combating fraud, waste, and abuse (FWA) positions us to outline contract language that ensures MCOs have adequate controls to avoid unnecessary spending.

 

Encounter Data Management, Validation, and Analysis

While similar to claims data, encounter data is unique to managed care and serves a unique purpose since states do not directly pay providers. States are required by federal law to report encounter data to the Centers for Medicare & Medicaid Services (CMS) as part of their quarterly Medicaid Statistical Information System submissions. Adequate validation and oversight of encounter data begins with drafting adequate contract requirements, but also entails implementing adequate system controls and collaborating with plans. We can help state Medicaid agencies

  • Comply with federal encounter data reporting requirements
  • Reduce administrative burden by aligning data submission standards with what is realistic for health plans and the state
  • Integrate with MCOs’ management and reporting systems in order to stay abreast of service authorizations, encounter data, and appeals
  • Improve the accuracy and completeness of the data
  • Strengthen states’ capacity to analyze and use the data to evaluate and monitor managed care program outcomes

Provider Screenings, Enrollment, and Management

Properly managing the provider network enrollment process is one of the most proactive and effective ways to mitigate the risks short-term financial losses and future network adequacy issues.


CMS’ proposed rule (CMS-2390-P) would make the federal guidelines for screening and enrolling Medicaid providers consistent across managed care and fee-for-service and transfer these responsibilities to the state. 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 states identify fraudulent providers, uncover illegal provider operations, reveal noncompliant provider activity, verify or disprove a provider’s service location, and satisfy the federal site visit requirement. By combining program integrity efforts to combat 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.

 

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