State of North Carolina Department of Health and Human Services (DHHS)

Developed and implemented a strategy by which the state of North Carolina would receive reimbursement for prescription drug costs for its state-operated long-term care facility residents enrolled in Medicare Part D.

The residents of North Carolina’s intermediate care facilities for persons with mental retardation (ICF/MRs) and institutions for mental disabilities (IMDs) are typically eligible for both Medicare and Medicaid. Historically, Medicaid reimbursed facilities for most prescription drugs, a considerable cost driver for this population. With the advent of Medicare Part D in 2006, this new program became the key payer for prescription drugs. The state had to develop both a strategy and a system to navigate the Medicare Part D program, a complex system of dozens of private insurance plans.

PCG Health™ worked with North Carolina to achieve the ultimate goal of a claims management system by combining its expertise in the healthcare landscape with its capabilities in advanced information technology. Leveraging existing relationships and developing new ones, PCG Health guided North Carolina through the regulatory, business, and technology aspects of the Medicare Part D program. PCG took careful and deliberate steps to ensure that the Department of Health and Human Services met several goals:

• Maximize Medicare Part D revenue received for prescription drugs;
• Identify and implement technological and operational efficiency improvements; and
• Ensure compliance with federal regulations.

PCG Health’s partnership with North Carolina resulted in the successful design, development, and implementation of a claims management system that connected the state to all major Part D plans. PCG Health developed the technology to receive and process data, submit claims, and manage and resubmit rejected claims. PCG Health ’s suite of reports allowed for analysis of payment patterns to further maximize revenue and provide the client with up-to-date project status information.

Key accomplishments included:

• Collection of more than $13 million for the first 18 months of the Medicare Part D window, including the collection of retroactive payments from 2006;
• Contracts established and all standards met for the integration of state pharmacy system into all major plan networks;
• Development and implementation of an online claims management system that provides decentralized access of all rejected claims to all pharmacy locations;
• Presentation of a suite of reports and analysis that contribute toward increased revenue and compliance.