Medicaid consulting for managed care organizations (MCOs)


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The Milliman Medicaid Consulting Group uses our consultants’ many years of experience to leverage our knowledge, research, and analytic tools across the firm. Milliman has more health insurance actuaries (over 270) who are members of the Society of Actuaries than other consulting firm in the U.S. The breadth and depth of knowledge available through this consulting group also enables us to create customized solutions for Medicaid MCOs in an effective and efficient manner. We have published numerous research papers covering topics that are important to our clients and the industry, including:

  • Nationwide managed care financial results
  • ACA health insurer taxes
  • Impact of Hepatitis C drugs on Medicaid programs
  • Dual demonstration models

From our work with Medicaid MCOs and healthcare providers—as well as our work with state agencies—we have the perspective to fully understand the factors driving the major stakeholders in the Medicaid continuum.

The foundation of the Milliman Medicaid Consulting Group is the experience of our consultants and actuaries with developing client-focused solutions to Medicaid rate-setting while helping guide regulatory oversight and ensuring compliance within each of our projects.

We have experience with:

  • Financial experience review—past, present, and future
  • Budgeting support including reserves, trends, and projections
  • Expert testimony support
  • Feasibility of entering new markets
  • Liability estimates (e.g., IBNR, PDR)
  • Assistance with risk-based capital
  • Analysis of provider reimbursement levels
  • Multiple risk adjustment models as applied to the Medicaid population

We apply historical context to all our work for our clients and discuss the factors that contribute to the current state of affairs. We also look ahead to give an idea of what the future may hold.

Managed care contract performance

Milliman assists MCOs with the sophisticated data analysis needed to compare providers of varying size that serve differing patient populations. We have applied our broad expertise in this area to assignments throughout the United States.

We help MCOs employ contract performance analysis to reduce healthcare costs while maintaining quality of care. We excel in creating financial models designed to cross-compare providers on an equal basis, adjusting for differences in their services and patient populations. These models enable us to perform precise actuarial analysis and offer impartial advice based on statistical, rather than anecdotal, evidence. Our process enables us to isolate inefficiencies and quality problems as well as identify outstanding providers.

Operational consulting

Coupled with in-depth knowledge of Medicaid programs, Milliman healthcare consultants come from a variety of backgrounds (clinical, IT, operational, and marketing) to provide a full spectrum of services.

Operations

Milliman reviews providers’ operations for effectiveness and compliance with CMS and/or state requirements, including staffing levels, risk score optimization, coding improvement, waiver support, marketing/sales, and IT capabilities. Milliman also benchmarks administrative costs and efficiency.

Operations and compliance go hand in hand. Milliman compliance experts help assess and optimize compliance by conducting mock audits, including educating, training, and coaching staff and preparing audit samples. Milliman evaluates and recommends improvements for compliance programs, compliant operations, delegation oversight, corrective action plans, policies and procedures, and continuous internal surveillance processes.

Healthcare management

Milliman’s clinical consultants help minimize inappropriate benefit expenses by assisting with building and/or evaluating internal and vendor healthcare management programs to achieve best practice in prior authorization, concurrent review, retrospective review, demand management, case management, disease management, and wellness functions.