State Medicaid Programs Brochure
Managed Care Advisory Services
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November 09, 2021
State Medicaid Programs Brochure
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As Medicaid enrollment in most states is growing and the expenditures are increasingly becoming a larger portion of state budgets, Medicaid Managed Care serves an important role in driving innovation, quality improvement and financial performance across all programs.
Our Medicaid Managed Care experts’ depth of understanding and hands-on experience allow us to work closely with state governments on a host of issues involving Medicaid for health plans, providers and vendors in publicly financed programs.
Analytics and Reporting
As new programs are added and existing programs change, it is critical to see, understand and report on key metrics that impact performance, revenue, compliance and ROI. Our team can give you a firm foundation using analytics to place a value on your programs with optimized reporting, so you can see the performance measures that make the most impact.
Services include:
- Perform qualitative and quantitative analyses of existing or new program changes
- Design and build dashboards and reporting tools
Procurement
Helping your organization tell its unique story while satisfying each requirement requires a special blend of experience, compassion and communication.
Services include:
- Provide strategic advisory for the writing process to enable optimal messaging
- Provide technical advisory and training procurement process, evaluation, compliance and integrity services
- Create targeted updates of requirements and program standards
Actuarial and Rate-Setting
Accurate financial and actuarial calculations are critical for plans and projections and for supporting decision-making.
Services include:
- Review, strategy, negotiations, best practices
- Value-based initiatives, shared savings, risk models, social determinants of health (SDOH), pandemic modeling
- Advise on innovation in rate development
- Financial analysis, forecasting and actuarial projections
- Incurred but Not Reported (IBNR) and reserve-setting
- Data science-based methodology
Risk Adjustment, Including ACA
An accurate and compliant risk-adjustment process leads to predictable revenue and better targeted member care. A poor risk-adjustment program can be a major compliance risk and can inaccurately reflect your organization’s member population.
Services include:
- Validate data quality, methodology and results
- Assess compliance with program and risk-scoring; reflect intended representative membership
- Ensure provider participation
Contracting
Healthcare in the digital age requires an updated perspective on procurement standards in addition to assessment of the new vendors, providers and services available to impact member care.
Services include:
- Provide oversight of provider contracts for managed care organizations (MCO)
- Evaluate other state and MCO vendor contracts
- Provide recommendations for improvement
- Provide strategic advisory for the overall contracting process
Implementation and Readiness Review
Implementations can wear down your team with work above and beyond normal duties. Our team will be an experienced, independent party that will facilitate and guide your implementation, and align and update your people, processes and technology so the organization comes out stronger than before.
Services include:
- Evaluate completeness of plan submissions and vendor readiness
- Create targeted updates of requirements and program standards
Experience Evaluation
Benchmarking your performance against peers is an important component of achieving your vision and mission. Our team can illuminate your gaps, help you close them, and steer you in the right direction to accomplish the unique goals of your company.
Services include:
- Analyze current managed care experience against expectations
Networks
A strong network provides the quality of and access to care required by your state. Our experienced team right-sizes your network so that you and your members get the best care at the right value.
Services include:
- Evaluate adequacy of access to provider network
- Optimize networks to fill gaps, improve quality, and achieve financial expectations
- Assess contracting strategy such as value-based care to remain complaint
Additional Services
- System assessments, integration and
- operational support
- Litigation support of provider disputes
- Encounter operations and oversight consulting
- Value-based care and payment models
- Social determinants of health
- Operational risk assessments
- Utilization benchmarks/roadmaps
- Medical cost efficiency process improvement
- Medicaid program support
- ACA marketplace
- State government operations
- Third-party administrator (TPA) services
Case Studies
Client 1: Medicaid Implementation and Systems Assessment
Situation: A Medicaid Health Plan was experiencing challenges related to simultaneous consolidation and integration with a competitor, during a large-scale Medicaid implementation.
Our Role: FTI Consulting brought a cross-functional team of clinical, Medicaid and technology experts to help the organization choose which entity’s core systems were both the best long-term choice and would best prepare the surviving entity for the critical implementation. Our group then led the execution of the system implementation, MIS workstreams, architecture, transition of vendors, financial modeling, advisory, program management, Medicaid Advisory, governance, project management, analysis, and clinical operations support.
Our Impact: Using FTI Consulting’s expertise, the consolidated organization made the necessary people, process and technology decisions to work on multiple work streams while simultaneously doubling the size of their organization.
Client 2: PACE Program Claims Review
Situation: FTI Consulting was asked by a leading Health System, which also operates as a Program of All-Inclusive Care for the Elderly (PACE), to review claims related to the PACE program.
Our Role: We repriced the claims, comparing to contractual terms, and summarized the variances with Health System’s leadership for purposes of recovery.
Our Impact: The Health System’s leadership team had both the data and a plan to move forward with claim recoveries.
How We Help Our Clients
- Enhance state provider management, support and oversight
- Increase efficiencies by utilizing best-in-class analytics and operational processes
- Access best-in-class claims data for benchmarking and trending purposes
- Implement industry-leading contracting and value-based care (VBC) options
- Identify major sources of operational risk and create mitigating controls
- Conduct comprehensive operational and compliance reviews
- Provide strategic and financial planning expertise
- Reduce costs and improve value through medical finance and healthcare economics
FTI Consulting Health Solutions
Our integrated team of industry experts provides holistic, specialized capabilities across providers, payors and life sciences with a dedicated center for healthcare economics. FTI Consulting’s subject-matter experts have a record of success in business transformation, restructuring, technology, transactions, cybersecurity, strategic communications, competition economics, investigations, disputes, clinical operations, data analytics and more.
We aim to support our clients through every step of their journey and partner with them to optimize performance in the short term, as well as prepare for future strategic, operational, financial and legal challenges.
Meet the Expert
Christian Jensrud has more than 28 years of Medicaid and Medicare healthcare, managed care, consulting, executive leadership, growth, and business development experience. Mr. Jensrud has extensive experience managing large and small project teams with work related to Medicaid Managed Care. Services includes operational advisory, cost management, revenue enhancement, and risk mitigation. Areas of expertise: medical economics, pharmacy analytics, reporting, strategy, budget oversight, contract management, resource allocation, and strategic management.
Prior to joining FTI Consulting, Mr. Jensrud served as the Chief Growth Officer for Fluent Health at Presbyterian, a Principal and Office Business Leader for the Mercer Health and Benefits Government Consulting Practice and as a Vice President for Anthem Amerigroup.
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Published
November 09, 2021
Key Contacts
Managing Director
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Healthcare & Life Sciences
Health Solutions