Category Archives: Government

Vermont cites improved health exchange, Optum contribution

Vermont is publicly touting the improvements in its health insurance exchange, Vermont Health Connect (VHC), and has cited work by Optum, VHC’s systems integrator, as a big reason for their success. Administration officials recently delivered their final monthly report on VHC to the state legislature, a largely positive document that listed numerous improvements and successes […]
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Calculating the incalculable

We often hear from state program integrity units that the work they do goes unrecognized. Yet when quizzed on how they promote their efforts — which could result in millions of dollars in savings and recoveries over just one year — they often reveal a limited understanding of how to calculate these savings. After all, […]
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Maintaining your provider network: Tips for keeping docs despite an audit

As a Medicaid agency, you’re tasked with maintaining a provider network of sufficient size, quality, geographic range and breadth of services to meet the needs of your state’s most vulnerable population. But maintaining positive, productive provider relations during a recovery audit can be challenging. One thing you can do is build up a store of […]
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Getting behind the science: Program integrity, predictive analytics and best practices

Whether you pluck the petals from a daisy or gaze into a crystal ball, the traditional means of predicting and influencing future events has always carried a high degree of risk. Fortunately, when it comes to analyzing claims data, there are proven methodologies —predictive analytics — that states can use to help assess the validity […]
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10 tips for working with MCOs to advance Medicaid program integrity

Have you turned to managed care organizations (MCOs) to reduce Medicaid costs and improve patient care? If so, you probably know how difficult it is to know for sure whether your MCOs are doing all they can to reduce fraud, waste and abuse. In May 2015, CMS proposed a new rule that MCOs strengthen their […]
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Excessive incarceration of individuals with mental health and substance use disorders: Jail diversion programs may be the answer

The number of individuals with mental illness and substance use disorders in U.S. jails and prisons is troubling, with estimates ranging from 360,0001 to more than a million.2 At least 30 percent of incarcerated adults have a serious mental illness, and approximately 65 percent have a substance use disorder. Twenty-five percent have both.3 Now, an […]
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Suspend Medicaid benefits of the incarcerated rather than terminating them

When individuals are incarcerated, most states terminate Medicaid benefits. Problems arise, however, as prisoners are about to be released. Administrative delays and state regulations often result in a gap of several weeks before coverage resumes — a critical period of time for former inmates struggling with mental illness, addiction or a host of high-level chronic […]
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5 reasons why Medicaid agencies should use cloud-based services

To what degree has your state made the move to cloud-based services? More and more states are successfully implementing data processing and hosting solutions in the cloud. These anything-as-a-service (XaaS) solutions can be more cost-effective and responsive to changing needs. When will your state Medicaid agency get on-board? To help you overcome any concerns, here […]
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Ditching MMIS full-system procurement for a “services-only” approach: A quick “how-to” on administrative operations

Adopting a service-based Medicaid Management Information System (MMIS) approach may require that you reorganize some of your administrative operations. For example, you’re probably using your MMIS for capitation payments and the collection of encounter data — but you don’t have to. You can make capitation payments through your finance system and feed your encounter data […]
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Rethinking your MMIS? A services-only approach does qualify for enhanced FFP.

Many people have asked whether a service-based model for Medicaid Management Information System (MMIS) qualifies for enhanced federal funding. The answer is yes. As you know, the federal government requires states to undergo certification to receive enhanced Federal Financial Participation (FFP), which pays 90 percent for MMIS implementation and 75 percent for ongoing operations. What […]
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