health-plans

Health Plans
Case Studies

Data Submission

Summary

A health plan sought our team’s help to put corrective actions into place after it faced several issues submitting data to the state, which caused the company to face multiple fines and sanctions. Our team used various tactics to identify problems in the company’s submission process, and provided solutions for preventing future problems.
 

Challenge

  • A medium-sized health plan had several issues submitting data to the state and needed external expertise to identify problem areas and make recommendations for future compliance
  • The health plan was facing potential fines and sanctions imposed by the state based on these issues
  • The client’s goal was to put corrective action plans into place prior to bidding on additional state Medicaid business
  • The client needed reviews of existing internal processes, previously collected data, and the programs developed in support of the required submissions

Approach

  • We performed a gap analysis of the current submission file process and other workflows and business practices associated with collecting the data
  • We reviewed claims submission workflow, claims approval processes and system edits
  • We analyzed claims system data extract to ensure completeness and accuracy of existing data against state requirements
  • We identified gaps in data required and gaps in accuracy/cleanliness of data collected
  • We developed recommendations for process changes to remediate issues

Results

  •  We provided detailed change recommendations to process and/or data collection requirements and claims edits
  • We worked with the health plan to update and cleanse claims and encounter data to reflect required information
  • We delivered a comprehensive analysis of current state for each of the key review areas
  • We made recommendations for areas of improvement and/or correction for each of the key review areas
  • We created documentation for new data extract and submission files