Managed Care Organization (MCO) Audit Services |
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PHBV Partners LLP
Effective January 2, 2012, Clifton Gunderson’s Team Health Care has become PHBV Partners LLP. In addition, Clifton Gunderson and LarsonAllen, ranked as two of the nation’s top 20 certified public accounting and consulting firms have merged to form CliftonLarsonAllen LLP (CLA). PHBV Partners is a separate legal entity that will service our regulatory health care clients at the Local, State and Federal Government levels.
Medicaid is the nation's largest purchaser of health care services for low-income families. In fact, more than half of the nation's Medicaid beneficiaries are now enrolled in a managed care plan. With so much riding on MCOs, there are inevitable risks.
PHBV Partners offers specialized assurance services that address these risks. Our staff of experts can analyze your operations and effectively assess contract performance to answer questions critical to your success.
Some studies have shown that MCOs have become less forceful in their oversight of Medicaid services, highlighted by reduced requirements for prior authorizations. In addition, broader provider networks, while a benefit to Medicaid recipients, have increased the need for MCO oversight. Our audit services can provide crucial insight into MCO issues, including:
- Are providers properly credentialed prior to being included in a provider network?
- Are provider network lists accurate and up-to-date?
- Are provider inquiries and prior authorizations handled in a timely manner?
- Do call centers operate in accordance with contractual requirements?
- Are complaint and appeal processes adequate?
In addition to the performance of audit services, our experienced staff can also determine if MCOs inflate charges, double bill, or include unallowable costs in their reports or invoices to the state. If an MCO is a Preferred Provider Organization (PPO), our experts can determine whether the state is billed at the rates set by individual providers, or at the agreed-upon PPO-Provider rate which saves money for the state.
PHBV Partners also has a team of information technology (IT) experts to review IT issues affecting MCO computer system efficiency and accuracy. Our IT audit staff can review MCO processes and controls to ensure that changes to medical policies, coverage requirements and benefit limits are accurately reflected in computer systems that rely on this information to process prior authorizations and claims. Our IT professionals can also provide technical expertise regarding:
- Health Insurance Portability and Accountability Act (HIPAA) compliance
- Security of data and systems
- Disaster recovery and business continuity
- Reliability of data
For those states that put the responsibility of member enrollment in the hands of MCOs, we can assist oversight agencies to:
- Ensure that enrolled members are actually eligible for the program
- Determine if enrollment applications are processed in a timely manner
- Determine if ineligible applicants are properly referred to other programs for assistance
- Determine if claims were properly approved or denied based on accurate member participation dates
