Don't let the oversight risks of Home and Community-Based Service providers lead to poor quality of care and out-of-control costs.


PCG Health can review your current system of care, help you better define the quality and system goals, and assist in the development of outcomes measures that change the way your home and community based service delivery system works.

Addressing the Risks - The PCG Health Solution

Home and Community-Based Services (HCBS) include community and outpatient behavior health, personal care attendant services, home health, and hospice services. These services offer the benefits of increased client satisfaction and potential cost savings. But the rapid rise of home- and community-based services has also introduced challenges and risks, including diminished qualityof- care, unsustainable cost increases, decreased documentation compliance, and improper tracking and measuring of service outcomes.


To address these risks, PCG Health has developed a consulting solution to help states effectively monitor and ensure the delivery of cost-effective HCBS . 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.

Data Management and Analysis

PCG Health can quickly organize and integrate your state's Medicaid and other health care data, including claims, eligibility, and utilization information.

This step allows us to perform

  • Data warehousing – PCG's capacity to import and manage large volumes of Medicaid data allows for high-impact results with few demands on state IT resources.
  • Outlier Identification – We will identify historical trends and outlier providers and work with states to target providers for postpayment auditing.
  • System Modeling Analysis – Our team will closely analyze claims, eligibility, and utilization data to create a 'map' of your state's HCBS system.

Post-Payment Claims and Case File Audits

PCG Health's on-site 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 potentially 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 state clients to develop an audit report standard that fully supports our recoupment findings.


Pre-Payment Claims and Case File Reviews

Nearly 25 years of helping states with revenue cycle improvement services has taught PCG Health the advantage 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 aspect of the bill-pay cycle. We collect the required documentation from a provider for cases being billed to a state's Medicaid agency and review all documentation criteria related to the claim, as specified by the Medicaid agency and as prescribed by the corresponding Medicaid provider manuals.


Compliant claims are processed within days, while non-compliant claims are caught and returned on 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.

Provider Screening, Enrollment, and Management

The Affordable Care Act requires that states complete an on-site screening of all new high- and moderate-risk providers prior to Medicaid enrollment. PCG Health can execute these onsite screenings, as well as assist states in managing their provider population. By integrating outcomes Program Integrity efforts to combat fraud, waste, and abuse along with financial information regarding unpaid overpayments, PCG's integrated solution identifies audited providers or individuals who owe money back to the state. This ensures that no future payments are made while the provider is under investigation or owes back overpayment. PCG will also prevent problematic providers or individuals form from obtaining a new Medicaid provider IDs.


This allows for strong providers to enroll as Medicaid providers quickly and efficiently, while precisely screening out problematic providers with a history of fraud, waste, or abuse.


Provider Training and Communication

PCG Health can help states provide a valuable training resource to providers. Using program knowledge gleaned from our postpayment claims audits or pre-payment claim review process, we can develop state-specific provider training programs that instruct these providers in appropriate program and administrative billing procedures. Our process can include

  • development of training materials
  • on-site group trainings
  • Webinars
  • Web-based distribution of training materials

In addition to training, PCG Health's state-specific web portal will communicate with providers, with training materials and utilization / outcomes reports that include direct feedback on non-compliant claims.

Payment Policy Development

A deliberate process leads to sound payment policies and outcomes. PCG Health helps states develop meaningful, realistic outcome measurements and to find efficient ways to collect, analyze, and report those measures. We can help states to develop

  • process measures
  • transition of care measures
  • outcome measures

Our goal is to use all existing data to help states develop a payment approach that rewards proper provider behavior and produces the highest possible quality outcome measurement.


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Download the Program Integrity Consulting and Outsourcing 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 Medicaid Program Analysis and PERM Assistance Services please contact us at or 1-800-210-6113.