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Response to RFP No. MED13002 State of West Virginia ... - DHHR

Response to RFP No. MED13002 State of West Virginia ... - DHHR

Request For Proposal #

Request For Proposal # MED13002 Recovery Audit Contract – Pharmacy West Virginia Health and Human Services Our recovery audit service is the core of our business and continues to recover funds lost to errors and overpayments. We have tailored our Recovery Audit services to the specific needs of each industry we serve, including Healthcare Payers, Retailers, Manufacturers and Service providers. Beyond Recovery Audit, our services cover fraud prevention, detection and remediation. In addition to our Recovery Audit services, PRGX has Analytics and Advisory capabilities. Where applicable, our analytics teams can implement SaaS tools to help clients extract data, build reporting capabilities, manage communications with vendors and provide continuous control monitoring capabilities. Additionally, PRGX advisory capabilities offer extensive fact‐based, analytically sound recommendations for profit improvement. Our audit teams have deep functional expertise, a practical hands‐on approach, and wisdom to understand how to get things done in our clients’ organizations. We convert these recommendations into lasting improvements with our deep implementation skills and experience. One of Our Core Capabilities Pharmacy auditing is a fundamental part of the PRGX core capabilities. PRGX maintains a specialty division within our organization, which focuses primarily on the purchases made by pharmacies such as a retail pharmacy, or any other organization that purchases, pays for, and dispenses pharmaceuticals. The PRGX pharmacy audit team audits both the indirect purchases that a retail pharmacy and the direct purchases that a retailer makes from manufacturers to ensure that the negotiations between our clients and the wholesaler or manufacturer were actually captured in the retailers’ systems. Our pharmacy audit team identifies missed rebates, missed price protection, incorrect pricing, missed allowances, and incorrect extended dating, inaccurate pricing on returns and recalls, among others. PRGX’S Subcontractor PRGX is proposing to use Sagebrush Solutions, as subcontractor, to support the delivery of the Medicaid Pharmacy Recovery Audit functions for BMS. Sagebrush Solutions brings extensive Medicaid and Medicare pharmacy expertise, as well as private and public sector program integrity expertise, including industry analysis of fraud, waste and abuse (“FWA”) to the West Virginia Medicaid Pharmacy recovery audit contract. Their expertise has been demonstrated in the prescription drug benefit industry and Medicaid fraud reviews for CMS under the Audit MIC contract. Sagebrush is highly qualified and brings specific, relevant experience to our team as portrayed below. 11

Request For Proposal # MED13002 Recovery Audit Contract – Pharmacy West Virginia Health and Human Services Sagebrush was formerly a practice within the Health Care Consulting group of Ernst & Young LLP for over 7 years. On March 1, 2000, Sagebrush Solutions spun out of Ernst & Young LLP. As a subcontractor to PRGX, Sagebrush will be responsible for automated reviews for pharmacy claims submitted by providers of formularies for which the State of West Virginia have made payments. Sagebrush will also support and defend provider rebuttals and redetermination requests as well as provider appeals as applicable. Our understanding of the Statement of Work The West Virginia Medicaid Pharmacy Program is an optional fee‐for‐service benefit offered to all eligible members, including those individuals enrolled in Medicaid Managed Care plans. We understand that as part of the West Virginia Formulary most prescription and some over‐thecounter medications are covered as defined by federal law and regulations. In addition, we are aware that the West Virginia Pharmacy Program maintains a Preferred Drug List with established criterion for non‐preferred products. We further understand that, as prescribed by federal laws and the West Virginia regulations and policies, some medications on the West Virginia Medicaid formulary may be limited in quantity, by gender, or prior authorization requirements. PRGX understands the structure and responsibilities of the State of West Virginia Health and Human Resources. We understand that within the Within the West Virginia Department of Health and Human Resources, the Bureau for Medical Services (BMS) is the single state agency responsible for statewide administration of the Title XIX Medicaid Program, and as such is responsible for establishing the WV Medicaid RAC program. PRGX is aware that the West Virginia Medicaid program covers federally mandated services as well as a number of optional services. PRGX acknowledges that under broad federal guidelines, while meeting certain minimum standards, the state of West Virginia establishes its own standards for Medicaid beneficiary eligibility, benefits package, and provider payment rates. PRGX is acutely aware that the State of West Virginia, in compliance with Section 1902(a) (42)(B)(i) of the Social Security Act and Section 6411 of the Affordable Care Act, seeks to establish a contract that meets the requirements for a Medicaid Recovery Audit Contractor (RAC) for the West Virginia Medicaid Audit Program in accordance with the specifications contained in Request for Proposals (“RFP”) # MED13002. To achieve the goal of the West Virginia Health and Human Resources, Bureau of Medical Assistance (BMS), PRGX will identify improper payments made by the BMS Medicaid Program to 12

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