Grants, funding & Federal Programs Child Care Assistance and Federal Oversight Addressing fraud, waste, and abuse and ensuring compliance in child care assistance programs to secure federal funding and support families nationwide. Key Takeaways Federal funding for Child Care and Development Fund (CCDF) programs has been suspended for five states due to inadequate oversight and…
program integrity & Compliance The Case for Program Integrity in Medicaid Managed Care | Part 12 The Benefit/Program Integrity team is pleased to have had the opportunity to bring you the blog post series The Case for Program Integrity (PI) in Medicaid Managed Care and share our insights on PI to combat fraud, waste, and abuse (FWA)…
Program integrity & COmpliance The Case for Program Integrity in Medicaid Managed Care | Part 11 In our previous post on claims denials, we presented issues with the underlying data and other variables that influence effective evaluation of prior authorization (PA) and claim denials. We also discussed a few risks associated with PA and claim denials. In…
Program Integrity & Compliance The Case for Program Integrity in Medicaid Managed Care | Part 10 As we discussed in our previous posts describing the complexity of managed care organization (MCO) subcontractor oversight, we evaluated those intricate relationships and the program integrity (PI) challenges involved. We also presented real-world examples. Here, we dive into prior authorization…
Program integrity & compliance The Case for Program Integrity in Medicaid Managed Care | Part Nine In our previous post on subcontractors, we talked about the nuanced aspects of managing PI and addressing FWA within the realm of managed care organizations (MCOs) and their subcontractors and related entities. Here, the Benefit/Program Integrity (PI) team provides…
Program Integrity & COmpliance The Case for Program Integrity in Medicaid Managed Care | Part Eight In our previous post, the Benefit/Program Integrity team discussed problematic encounter data, how it factors into rate setting and the medical loss ratio, and provided recommendations alongside a case study. In this resource, we address the nuanced aspects of…
Program Integrity & compliance The Case for Program Integrity in Medicaid Managed Care | Part Seven In our previous post on encounter data, we offered recommendations for meeting the challenges of problematic encounter data. In this installment, we present a Case Study from one of our own engagements, in which we helped our client transition from PI…
Program Integrity & Compliance The Case for Program Integrity in Medicaid Managed Care | Part Six Encounter Data Recommendations The Impact of Incorrect or Incomplete Data: In our previous post on encounter data, we discussed how faulty encounter data can affect rate setting and create ongoing program risk. In this post, we offer recommendations for managing potential…
Program Integrity & Compliance The Case for Program Integrity in Medicaid Managed Care | Part Five Encounter Data and Problematic Data The Impact of Incorrect or Incomplete Data: As we discussed in our previous post, the medical loss ratio (MLR) structure may incentivize MCOs against pursuing program integrity (PI) to fight fraud, waste, and abuse (FWA). Here, we detail how faulty…
Program Integrity & Compliance The Case for Program Integrity in Medicaid Managed Care | Part Four The Medical Loss Ratio at the Intersection of Program Integrity and Fraud, Waste, and Abuse Why managed care organizations are NOT incentivized to find fraud, waste, and abuse (FWA) Key Takeaways In our previous post, Does your MCO Contract Encourage Program Integrity efforts? our Benefit/Program…
Program Integrity & Compliance The Case for Program Integrity in Medicaid Managed Care | Supplementary Insight In our previous posts about program integrity (PI) and fraud, waste, and abuse (FWA) within the managed care space, our Benefit/Program Integrity team raised several critical issues, starting with the headlines around PI and FWA within managed care organizations (MCOs). We looked at how contract language may not support…
program integrity & compliance The Case for Program Integrity in Medicaid Managed Care | Part Three Does Your MCO Contract Encourage Program Integrity Efforts? As we discussed in our previous post, Understanding the Link Between Program Integrity (PI) and Managed Care Contracts — and Why It Matters to States, contract language is an often overlooked but essential part of PI. In this installment, we…