    
        Top 3 Areas of Impact    
            
                        Improved Revenue Forecasting
                    Clear visibility into state rules and timelines enabled more accurate projections and stronger financial planning.
                        Reduced Missed Revenue
                    Identification of operational and data gaps helped the client proactively address issues impacting encounter acceptance.
                        Stronger Cross-Functional Alignment
                    A unified playbook and stakeholder engagement created shared understanding and consistent execution.

Client Overview

The client is a national insurer serving in a state as a regional managed care organization (MCO) providing Medicaid coverage

Deliverables

State Requirements Playbook
Operational Assessment & Gap Analysis
Implementation Plans & Desk-Level Procedures

What Drove the Engagement

Challenge

The client wanted to gain visibility into state requirements for risk-based supplemental revenue arrangements that are part of the Medicaid contract agreement established between the state and MCOs offering Medicaid coverage. In the absence of this visibility, the client was unable to proactively mitigate sources of missed revenue and accurately forecast revenue projections, therefore, negatively impacting business planning and prioritization decisions.

Solutions

ProspHire conducted a thorough assessment of current state operational and governance capabilities through stakeholder interviews and analysis of encounter data and feedback files provided by the state. Concurrently, the team conducted research to document state requirements and review timeline for the risk-based revenue streams along with best practices to maximize revenue capture.

Impact

ProspHire delivered a comprehensive playbook documenting rules and conditions utilized by the state to accept encounters for revenue consideration. In addition, the playbook outlined implementation plans and desk level procedures for reporting processes to enable prospective audits into the accuracy and completeness of claims being submitted to improve likelihood of acceptance. ProspHire socialized identified opportunities with impacted stakeholders to gain engagement, alignment and mobilization.