Managed Care Organization (MCO) Oversight is an essential component in ensuring that managed care programs operate efficiently to provide the best care to Medicaid members. PCG’s Managed Care Oversight team works across the U.S. implementing a comprehensive solution that integrates data analytics, federal and state compliance, and continuous program improvement to meet state goals.
Services include
Stakeholder Engagement
Our stakeholder strategy merges project management best practices with community outreach, focusing on a comprehensive communication plan. Stakeholders in managed care oversight programs include state leadership, state compliance and programmatic staff, managed care plan compliance, programmatic, data analytics staff, and a software solution team.
Designing Evaluation Methods and Reporting
PCG advises and creates data collection methods for our clients that are user friendly, automated, and meet federal and state requirements. Depending on client need, PCG may create a holistic environment for data collection, or leverage a state’s existing system. Data reference tables, Key Performance Indicators (KPIs), and guidance documents provide direction for the review of Plan submitted information, and support data driven decision making for states.
Upon receipt of MCO report submissions, data is loaded and automated data validation checks are executed. Files passing validation are used to support state reporting, managed care plan (MCP) oversight, and other analytic explorations. Files failing validation will be rejected with specific remediation needs detailed to ensure future MCO reporting compliance.
Meeting Regulatory Requirements
Federal: PCG maintains subject matter expertise in all federal reporting requirements including the Managed Care Plan Annual Report, CMS Final Rules, 1115 waiver evaluations and progress reporting, CMS programs for special populations (i.e. Money Follows the Person) and more.
State: PCG reviews the state’s contract with MCOs and other state-provided documentation for programmatic efforts that detail benchmarks and goals for MCP performance.
Technical Assistance
For State Staff: PCG develops standard operating procedures that guide staff through report reviews and
offers technical assistance on all aspects of the MCP reporting package.
For MCP Staff: PCG develops guidance documentation and hosts office hours and technical assistance workshops to support MCPs in providing the best possible data and steps they may take to improve their performance on key measures.
Recommending and Implementing Policy/Program Changes
MCP oversight often results in findings that guide and promote policy and programmatic changes. PCG’s data analysts’ and policy experts work together to recommend and implement policy and programmatic changes to improve MCP performance, ultimately improving care for a state’s Medicaid population and improving overall program effectiveness.