State Medicaid Programs Brochure

Managed Care Advisory Services

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.

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

Key Services

Growth Strategy

Growing your Medicaid footprint is successful when it is intentional. Understanding the pros and cons of each market leads to successful new market launches.

Services include:

Review of current capabilities and financial condition
Evaluate competitor landscape including operational and financial capabilities analysis
Develop potential other lines of business(MA, DSNP, ACA) opportunities for market entry that lead to Medicaid entry
Develop a market tiering process that includes factors for successful market entry, weighting the important of each factor, and scoring each market
Create a market entry strategy for Tier 1 markets
Strategy execution and implementation support
Advisory related to funding needs for new opportunities

Capability Assessments & Roadmaps

Capabilities assessments provide ongoing review of policy and regulations for MCOs to improve operations and programs to better serves members, maintain differentiated products, prepare for upcoming procurements, and provide the optimal partnership for state Medicaid agencies.

Services include:

Review of current Medicaid policy and regulatory trends and initiatives to pressure test current capabilities against them
Develop operational assessment tool that incorporates policy trends, state Medicaid contract requirements, and MCO initiatives
Conduct objective assessment and score how well the MCO meets the assessment elements and level of effort to remediate
Develop remediation road map
Assist with road map execution

Procurement

Helping your organization tell its unique story while satisfying each requirement requires a special blend of experience, compassion and communication.

Develop pre-Procurement strategy, evaluation, planning, and market positioning
Provide strategic advisory for the writing process to enable optimal messaging
Provide technical advisory and training procurement process, evaluation, compliance and integrity services
Independent mock scoring with an independent view of the quality of an RFP response
Create targeted updates of requirements and program standards
Finalist meeting preparation
Perform competitive analysis on other bidders and post-award debriefing
Partner with law firms on procurement protests

Implementation & 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:

Project management services to oversee the implementation process and strategy
Evaluate completeness of plan submissions and vendor readiness
Create targeted updates of requirements and program standards
Network development and provider contracting support

Operational and Policy Expertise

Helping plans and vendors address operational challenges to ensure programmatic compliance and maximize operational efficiencies.

Services include:

Medicaid policy analysis and technical assistance understanding state specific requirements and regulations
Pharmacy program optimization
Mental Health Parity
Population health management strategies
Quality improvement
Fraud, Waste and Abuse
Technology and Digital
Perform regulatory risk assessments
Delegated vendor oversight programs
Operational assessment related to mergers, acquisitions, integrations, and change
Medicaid Managed Care executive staff augmentation

Provider & Community Based Networks

The role of highly performing and differentiated networks is important to meeting value-based purchasing requirements, effective care management delegation, and strategies to address social determinants of health and health equity.

Services include:

Assess contracting strategy such as value-based care to enable provider risk relationships
Strategy for social care networks leveraging community-based networks
Identifying best in class health, behavioral health and social care providers
Evaluate network performance against state equality measures
Optimize networks to fill gaps, improve quality, and achieve quality expectations
Coordination with CCBHC

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.

Design and build dashboards and reporting tools
Capitation rate review and negotiations
Advise on innovation in rate development and risk adjustment
Financial analysis, forecasting and actuarial projections
Incurred but Not Reported (IBNR) and reserve-setting
Validate risk adjustment data quality, methodology and results
Medical cost efficiency process improvement

Vendor Community

A myriad of vendors (digital, PBM, dental, TPA, provider-enablement organizations, risk bearing providers, data platforms, information technology, etc.) have developed solutions to support health plans meet Medicaid program requirements.

Services include:

Develop pre-Procurement strategy, evaluation, planning, and market positioning
Provide strategic advisory for the writing and mock scoring process to enable optimal messaging
Provide technical advisory and training procurement process, evaluation, compliance and integrity services
Finalist meeting preparation
Perform competitive analysis on other bidders
Perform post-award debriefing
Partner with law firms on procurement protests

Case Studies

Client 1: Medicaid Implementation and Systems Assessment

Situation: A Medicaid Health Plan was overwhelmed with a large-scale Medicaid implementation prior to merging with a competitor.

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 implementation, including preparing the chosen systems, many of which were from the company being acquired, for go-live.

Our Impact: Using FTI Consulting’s expertise, the consolidated organization made the necessary people, process and technology decisions to implement successfully 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.