ACA’s expertise in managed care oversight ensures that our customers provide quality care to their clients in the most cost-effective manner. This expertise is evidenced by our successful performance of HealthChoices oversight, Pennsylvania’s mandatory managed care program for medical assistance recipients, since the inception of HealthChoices in 1997.
We possess the technical expertise in health information systems and data interpretation to help human services agencies overcome the challenges inherent in successful program monitoring, including understanding idiosyncratic reporting requirements, transmission of voluminous amounts of data to numerous funding and regulatory authorities, assessing compliance with provider and industry standards, and extracting meaningful information to assess program performance.
ACA’s expertise in the area of managed care oversight includes:
- Monitoring data submissions to ensure compliance with regulatory reporting requirements, while maintaining the confidentiality of protected health information
- Communicating health data according to industry standards, including HIPAA-compatible 837 encounter claims transactions and 834 benefit enrollment/disenrollment transactions
- Analyzing data to identify and resolve problems in claim processing, eligibility maintenance, and capitation reconciliation
- Participating in audits
- Evaluating organizations’ data systems, business processes and financial stability to assess their performance
- Familiarity with industry standards regarding managed care financial issues, including aging of claims, calculation of incurred but not received claims costs (IBNR), calculation of per-member-per-month (PMPM) costs, etc.
- Reconciling revenues against statistics of covered populations, as well as the cost of rendered services against capitation payments
- Monitoring provider networks to ensure compliance with standards of provider choice and access to care
- Implementing reporting data warehouses to give customers access to pre-written reports regarding service utilization, penetration, consumer characteristics, recidivism, length of stay, etc.
- Utilizing information from a data warehouse as the basis for an Online Analytical Processing (OLAP) database, allowing our customers to design their own reports to explore patterns in data
- Providing independent verification of the consistency and integrity of data systems implemented by third-party contractors