State Medicaid Programs Brochure
Managed Care Advisory Services
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November 09, 2022
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.
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.
Published
November 09, 2022
Key Contacts
Senior Managing Director
Managing Director
Managing Director
Managing Director
Managing Director