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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 2.3.3 References § 2.3.3 The Vendor’s proposal should include at least three (3) business references that demonstrate the Vendor’s prior experience providing RAC services. Each reference should include: § 2.3.3.1 The name, address, and telephone number of the organization; § 2.3.3.2 The name, telephone number, and email address of the responsible project administrator or project manager familiar with the Vendor’s performance; and § 2.3.3.3 A brief description of the project, including type of project, project goals and objectives, project beginning and end dates, services provided, and project outcomes regarding scope, budget, and schedule. PRGX recognizes that the successful performance on previous contracts is the best indicator of successful performance on future contracts. In accordance with the instructions listed in the RFP, PRGX is providing past performance references for our organization as well as for our subcontractors. These referenced projects are both similar in size and scope to the State of West Virginia solicitation requirements. Our past performance references and strong customer endorsements exemplify PRGX’s commitment to consistently achieve measurable results for our customers in the areas of performance management, infrastructure optimization, cost and risk management, enhanced operations efficiency and mission effectiveness as well as return on investment. Texas Medicaid Overpayment Recovery Audit Client Organization: State of Texas Client Contact Name: Chris Escalante Client Contact Title: Comptroller of Public Accounts Client Contact Information: 512.463.8902 Chris.Escalante@cpa.tx.us PRGX Role: Sub-Contractor Service Dates: 2008-2010 Contract Status: Completed per schedule Description of Work Perform Medicaid Overpayment DRG Audit on Inpatient claims for State of Texas. (PRGX performed the Medicaid Overpayment Audit as a subcontractor to Horn and Associates, who was contracted to perform a state-wide accounts payable audit for the State of Texas) Develop Government Control Council to oversee program execution Develop audit scenarios and queries based on Medicaid payment policies and applicable guidelines Audit claims for administrative compliance, coding and medical necessity over/under payments 21

Request For Proposal # MED13002 Recovery Audit Contract – Pharmacy West Virginia Health and Human Services Performance Results Staffing Levels Positions Included Contract Type Submit edited claim file for re-adjudication and re-processing Communicate with providers via approved correspondence and internal call center Submit routine reports on identified findings, collections and appeals Support Health and Human Services Commission throughout the appeals process Total $ claims analyzed: $1.8 Billion Total # claims analyzed: 500,000 Number of reviews performed: 9000 Provider response rate: 98% Total identified: $12.8 Million Total collected to date: Average $4,500 per claim Total claims appealed: 5.2% Total decisions overturned: 1% (full) 0.49% (partial) 18 Full-time employees Project Director Medical Director - Certified Coders - Registered Nurses - Audit Specialists Systems Administrator Record Imaging Specialists Call Center Specialists Contingency Fee 22

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