Business Readiness
Medicaid Business Execution
Background
The Affordable Care Act presented a tremendous expansion in the Medicaid segment, however many health insurance companies had limited confidence in providing Medicaid business and the ability to expand into this growing business segment.
Challenge
Our client, one of the largest pharmacy benefit management (PBM) companies, had limited experience and reputation in the Medicaid segment. The client wanted to optimize readiness for the Medicaid regulatory environment by building capabilities needed to effectively compete and serve their members.
Solutions
Project Solutions Group resources created a 3-year action plan for Managed Medicaid that accounted for existing roadmap projects, that ultimately led to increasing Medicaid membership by more than 800% over the three years.
Keys to Success
Background
The Affordable Care Act presented a tremendous expansion in the Medicaid segment, however many health insurance companies had limited confidence in providing Medicaid business and the ability to expand into this growing business segment.
Challenge
Our client, one of the largest pharmacy benefit management (PBM) companies, had limited experience and reputation in the Medicaid segment. The client wanted to optimize readiness for the Medicaid regulatory environment by building capabilities needed to effectively compete and serve their members.
Solutions
Project Solutions Group resources created a 3-year action plan for Managed Medicaid that accounted for existing roadmap projects, that ultimately led to increasing Medicaid membership by more than 800% over the three years.
Keys to Success
- Identified enhancements needed, and opportunities to leverage unused existing capabilities (e.g. Formulary management, Claims processing)
- Developed a process to manage state-by state Medicaid requirements to ensure regulatory compliance (E.g. Networks Contracts, Call Center)
- Enhanced Medicaid reporting by creating standardized reports to achieve the “gold standard,” based on current client targets with the most stringent reporting requirements