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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 2.4 Projects and goals § 2.4.1 The Vendor should describe their approach to identify and audit high risk claims with the potential for Medicaid under/overpayment collections. The description of the approach should address the following: Recovery Audit projects occur in three phases: Pre Audit, Audit and Post Audit. The identification and audit of high risk claims occur in the Pre Audit and Audit phases respectively. Pre‐Audit PRGX’s approach to identify high risk claims starts with robust project planning governance and client preparation, continues with Data receipt and validation and ends with concpet development (i.e Approval of audit strategy). The activities associated with project planning governance, client preparation, data receipt, analysis and validation and audit plan approval are as follows: 27

Request For Proposal # MED13002 Recovery Audit Contract – Pharmacy West Virginia Health and Human Services Tasks 1. Project Planning Governance 2. Client Preparation 3. Data Receipt & Analysis and Data Integrity Validation Associated Activities A 1‐2 hour conference call is set up between PRGX and client. This initial planning call is used to discuss the signing of key documents and an overview of the audit. A list of requested documents and data is also submitted by PRGX: Data dictionary for data extract to be received and key data fields to be sent. (Typically, data extraction documents are sent to client for review prior to call.) Letter drafts for provider communications Data transmission schedule (usually 30 days from the date of call), transfer method, and data contact. System Access: Client is informed PRGX will need access to claims system, applicable payment, claim processing policies for institutional (network and non‐network) and professional providers (network and non‐network related to fees paid, modifier discount rules) Key contacts and other information required to start audit (names of auditors, security access, etc.) Roles and responsibilities and process issues for the audit. PRGX obtains access to client payment policies, procedures, and systems. PRGX receives test data extract from Client. PRGX validates receipt and imports into proprietary tool for analysis. BMS provides any provider referrals for review. Analysis Validation Submitted to Client for approval 4. Concept Development (Query Development & Approval PRGX defines each specific improper payment scenario or audit concept to be utilized for each audit type Audit Plan submitted to client for review: initial audits and providers are submitted with rationale to client (within 30 days of data validation submission) Please note that the Audit Plan will be an evolving document based on the types of audits and referrals approved by the client 28

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