Medicaid Administrative Claiming (MAC)

Within the Medicaid program, costs must be classified as a “service” or “administrative” cost in order for it to be reimbursed to the state or locality that incurs it. The Centers for Medicare and Medicaid Services (CMS) recognize that state Medicaid programs rely on administrative activities that extend beyond the provision of direct services to clients. Individuals and organizations are responsible for locating, coordinating, and monitoring necessary and appropriate services for each Medicaid recipient. Additionally, states must identify and enroll individuals before they can access services. States are required to prepare cost allocation plans in order to quantify the costs of performing these required activities. Because the cost of these activities is often more difficult to quantify than direct service costs, mechanisms such as time studies are essential tools for measuring the level of effort that can be claimed for federal reimbursement.

• Medicaid outreach
• Medicaid eligibility determinations
• Referral to services
• Case planning
• Case management
• Development of an individual plan of care
• Case reviews

PCG Health can assist with claiming administrative costs, including case management costs, as either administrative or as Targeted Case Management (TCM). We may also review claiming opportunities for enhanced claiming for skilled professional medical personnel

PCG Health offers a number of services to help state agencies ensure compliance with federal regulations and identify opportunities for revenue enhancement. Services include:

• Activity and cost identification
• Federal claiming review
• Cost allocation plan (CAP) review and development
• CAP design, implementation, and management
• Indirect Cost Rate proposal preparation
• Review and development of time study methodologies, including Random Moment Time Studies (RMTS)
• Identification of systems costs and assistance with Advanced Planning Documents (APD)
• State Plan Amendments (SPA) for TCM claiming