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3 years ago

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 EXECUTIVE SUMMARY PRGX USA, Inc., in response to West Virginia’s Request for Proposal #MED 13002 takes this opportunity to respond to your requirement for a pharmacy recovery audit solution. In the attached proposal, PRGX provides the State of West Virginia with a pharmacy recovery audit solution that will not only satisfy the requirements of section 6411 of the Affordable Care Act (ACA), but one that will maximize recoveries on behalf of the West Virginia taxpayer, while ensuring that your provider relationships are not strained. PRGX’s proficiency in performing improper payments and fraud related risk assessment is unparalleled as evidenced in our past performance. In addition, PRGX‘s proposed subcontractor, Sagebrush will enhance our capabilities and audit concepts to provide the State of West Virginia with an effective and vigorous Medicaid pharmacy recovery audit program and fraud detection and prevention approach. With over 40 years of successful recovery auditing experience, PRGX has implemented audit programs for clients around the globe including some of the largest healthcare payors in the United States. Because of this experience, we have developed a very thorough understanding of healthcare claims data requirements along with proprietary tools and technology that enable us to perform successful auditing services for all our clients. These services include, identifying and recovering both underpayments and overpayments (as applicable), provider outreach services; correspondence with providers in the form of medical record requests and audit determination letters; maintaining and staffing a provider support center and administering and supporting claims through our clients’ entire appeals process. PRGX has a vast network of resources that will ensure consistent service delivery to the State of West Virginia. We can quickly bring to bear the resources of the largest global, publicly traded recovery audit company to assure continuity of excellent services on all our engagements PRGX’s Approach to BMS Recovery Audit The primary mission of PRGX’s Recovery Audit program is to improve the effectiveness, efficiency, economy and quality of the recoveries identified for our clients. While the State of West Virginia Bureau for Medical Services (BMS) maintains full program oversight, PRGX will extract, transform and load all necessary claims data, identify successful audit scenarios, correspond with providers as well as audit and re‐adjudicate claims that are paid incorrectly. PRGX will deliver excellent results with minimal program resource requirements from the 2

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