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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 2.3.1 Experience § 2.3.1 The Vendor should have at least eighteen (18) months experience in each of the following; § 2.3.1.1 State Medicaid pharmacy programs operations; § 2.3.1.2 Medicaid pharmacy program integrity issues and risk areas for waste, fraud and abuse; § 2.3.1.4 Auditing Medicaid pharmacy claims and reviewing medical records to determine overpayments, underpayments and/or improper payments; § 2.3.1.3 Medicaid pharmacy data analysis used to identify Medicaid overpayments, underpayments and improper billings; § 2.3.1.5 Medicaid pharmacy overpayment recovery; § 2.3.1.6 Medicaid fraud and abuse identification, notification, and support; § 2.3.1.7 Medicaid pharmacy provider appeals. The PRGX team brings both Medicaid pharmacy and industry audit expertise and strong experience to the West Virginia Bureau for Medical (BMS) engagement. Our audit staff, dedicated to improper payment identification and recovery, knows this business. We understand the pharmacy purchase‐to‐pay process, claims review and overpayment recovery; fraud waste and abuse trends and patterns, as well as data analytics and over the many years of auditing these transactions we’ve learned where to look for overpayments. In addition to our improper payment recovery audit capabilities, the PRGX team has also conducted data analysis and investigations for the purpose of identifying potential fraud. Our project experience includes gathering and organizing supporting detail for each potential case for further law investigation and prosecution by law enforcement. Moreover, our team includes litigation support professionals and testifying experts who have supported and provided testimony in more than 20 civil cases. Our team also includes two Certified Fraud Examiners. 15

Request For Proposal # MED13002 Recovery Audit Contract – Pharmacy West Virginia Health and Human Services 16

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