Each year, hundreds of millions of Medicaid dollars go to personal care services, home health, community behavioral health, hospice, non-emergency transportation, and other in-home care services. Managing these services – and their providers – requires a unique and innovative approach that is not traditionally available. Our innovative, comprehensive approach to HCBS program integrity and provider management is designed specifically for Medicaid.
PCG educates providers through enrollment, providing extensive initial training. Database screening and background checks flag and screen ineligible and high-risk providers to block them from enrolling.
We’ve conducted thousands of 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.
We help to ensure that all needs assessments and service authorizations are completed consistently and compliantly, integrating these with other program integrity efforts to avoid overbilling before services are delivered.
An inefficient appeals process can cost millions of dollars in unnecessary services. A non-compliant process can lead to lawsuits. Ensuring that all authorization appeals are efficient and compliant will save time and money.
Don’t wait to hear about a provider before you monitor it. Brief, high-touch, frequent, regular reviews of providers ensure compliance with policy and code. Routine reviews verify proper staffing, plans of care, level of service, and detect fraud, waste, or abuse. These reviews focus on correction, education, and cost avoidance.
Respond to complaints and reported incidents to ensure compliance and health and safety of beneficiaries. Investigations may focus on individual and/or providers, are initiated within days, and completed within weeks of notification.
As more services are delivered in the home and community, it is important to confirm the location of providers delivering services. Prevent paying for services not rendered using a mobile-based Electronic Visit Verification (EVV) system that confirms and documents a provider’s location, cross-referencing it with the expected location for that date of service and time of billing.
Our team flag high-risk claims and providers for pre-payment review and reviews supporting documentation for claims after submission, but prior to payment.
PCG conduct full-scale audits using data analytics designed to uncover extensive information and recoup large overpayments where payback is likely and the provider is prepared and qualified to continue to deliver services. The process includes Electronic Health Records Meaningful Use Audits.
PCG provides general and focused in-person, webinar, and online trainings for new enrollees and specific training needs.
We offer advisory services on workflow, staffing, systems and document management.
We can help clients shape policy based on findings, improve FWA, and facilitate wavier design.
Our solution includes dashboards and allows clients to analyze trends and monitor compliance of MCOs and providers.
PCG combines clinical program knowledge with technical expertise to maximize analytics software.
Measure and evaluate the impact of HCBS programs and PCG interventions.
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For more information about PCG Health's Program Integrity Services please contact us at
firstname.lastname@example.org or 1-800-210-6113.