Visibility into State Requirements Leads to Better Forecast and Revenue Projections


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.


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.


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.


  • Current State Operational Assessment
  • State Regulatory Requirements Playbook
  • Implementation Plan
  • Reporting and Auditing Desk Level Procedures

Client Overview

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

Let’s have a conversation

Lucas Blazejewski