Illinois Department of Human Services

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

The residents of Illinois’ 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 Illinois 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 Illinois 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 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 Illinois 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 unprocessed pharmaceutical data and formulate that data into an industry standard claim. PCG Health developed and implemented a system to submit claims and resubmit rejected claims until resolution. PCG Health’s online reporting tool and a 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 $15 million for the first 20 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 report management system that provides customizable reports to contribute toward increased revenue and compliance.
  

    “PCG Health™ has been an excellent partner in solving the complex problem of Medicare Part D billing…a tremendous asset in the overall planning process. Your experience and understanding of the Medicare maze helped us to overcome the many barriers that insurance and prescription drug plans put in our way. There were many times, except for your advocacy, we would have given up on some of our goals.”

Jim Hobbs, Manager
Office of Clinical, Administrative and Program Support
Illinois Department of Human Services