Medicaid Program Analysis and PERM Assistance

Medicaid programs have traditionally defined program integrity as errors related to MMIS editing and claims adjudication.  Historically, states have relied on their MMIS vendor or state staff with little to no independent monitoring of performance. In response, the Centers for Medicare and Medicaid Services (CMS) developed the Payment Error Rate Measurement (PERM) program to audit Medicaid programs for both eligibility and payment accuracy.

PCG Health™ can assist states in reviewing and enhancing the integrity of your MMIS operations as well as preparing for and responding to PERM audits as prescribed by CMS. Our consultants have more than 20 years of experience in all facets of the Medicaid operation, including MMIS edits and audits, program policies and procedures, recipient eligibility, quality controls, and best practices. 

• Evaluate MMIS claim and eligibility edits for compliance with State Plan
• Review Provider Manuals to ensure guidance supports MMIS edits and the State Plan
• Recommend necessary changes to MMIS edits, State Plan and/or Provider Manual

• Conduct pre-PERM reviews to identify any vulnerable areas
• Review of MMIS edits and audits to identify any potential weaknesses
• Recommend operational improvements to reduce errors

• Establish a methodology for conducting routine samples
• Document an audit plan
• Review monthly claim payment and eligibility files
• Calculate error rates by class of service, provider type, eligibility group, etc.
• Prepare monthly/annual reports of findings and recommendations for CMS

• Review/validate CMS PERM findings
• Prepare dispute response for applicable findings
• Implement operational changes to prevent future findings

PCG Health clients benefit not just from our ability to take a current snapshot. Our approach will also help states prepare and respond to CMS PERM inquiries. In addition, PCG Health will help states to make the operational and programmatic changes required to improve overall accuracy and timeliness of future payments.

PCG Health staff includes former CMS and state Medicaid officials with extensive related background and experience.  We’ve helped more than 40 health and human service agencies across the country with a broad spectrum of issues, and are uniquely positioned to assist clients with key program analysis tasks, including:

• Medicaid Recipient and Provider Eligibility
• MMIS Claim Payments Vulnerabilities
• State-operated and private provider reimbursements
• Medicaid Management Information Systems
• Program and policy/procedures analysis

PCG Health is ready to assist your state in identifying any programmatic or technological exposures and implementing corrective actions to tighten controls and prevent future payment errors.