Operational Support for Managed Care Optimization

We firmly believe that managed care can offer States better care delivery, providers simplified administrative processes, and beneficiaries improved health outcomes. Notwithstanding all other dynamics in a procurement situation, how soon you start and how hard you work are critical variables that are entirely under each applicant’s control. The year prior to the RFP release provide an important opportunity to assess and strengthen operations and optimally document your value to the managed care program – as well as tailor new innovations to address State goals.

We offer an exceptional project team ranging from junior staff support with the know how to manage projects and often serve as temporary staff to executive level consultants with vast experience in positioning for Medicaid MCO procurements and in identifying, designing and refining operational improvement opportunities. Our team brings strong relevant State market experience as well as valuable expertise and insights gained from supporting Medicaid managed care programs in dozens of other states.

The ways we plug in and support Managed Care Organizations depend on the extent of support sought. The following list provides examples of activities we have engaged in with clients.

• Identify strengths, weaknesses, and opportunities within a MCO’s Medicaid program. This assessment can be broad and include a review of all operational, clinical, network, and financial functions. We have also supported assessments of specific areas.
• Identify strategies to turn areas of opportunity into strengths that are aligned with the State’s goals and objectives.
• Identify data and develop data constructs to capture and demonstrate how past, current, and future initiatives are aligned with the State’s goals and objectives.
• Identify opportunities for enhancements to existing program and development of new programs that will yield short and long terms cost saving and that are aligned with the State’s goals and objectives.
• Support initial health plan or new contract implementation by: drafting policies and procedures, engaging in program implementation, and conducting mock audits.
• Support areas are identified as or at-risk for non-compliance by conducting root cause analysis, offering specific guidance as it relates to remediation, and technical assistance to act on recommendations.
• Develop processes in medical management and quality improvement to support improved provider experiences and member outcomes.
• Develop pilots and program initiatives to address identified gaps.
• Develop health equity strategies, programs, partnerships, and operational structures for competitive state RFPs.
• Assist health plans with NCQA Health Equity Accreditation and Multicultural Healthcare Distinction efforts including:
  • Establishing a framework and project plan to achieve accreditation compliance across Medicaid markets.
  • Developing and facilitating training for corporate and market-based health plan leaders across the organization on the Accreditation requirements and impacts across operational areas.
  • Managing NCQA Multicultural Healthcare Distinction applications.
  • Leading the development of process improvements across operations, including provider, quality, and member experience departments, to enhance the delivery of culturally competent and equitable services in compliance with NCQA standards.
• Assist health plans in establishing national, NCQA-compliant health equity and cultural competency programs and structure, including:
  • Authoring Health Equity and Cultural Competency Program Description
  • Providing strategic guidance in the development of quality-driven work plans aimed to improve CLAS and address identified health disparities.

• We supported a large commercial plan that newly acquired a Medicaid health plan. In addition to supporting the acquisition, The Menges Group was sought to support an operational assessment and technical support. We specifically supported the review and implementation of the plan’s QAPI program, provider relationship strategy, and clinical management programs.
• We supported a Medicaid focused plan by conducting a comprehensive assessment of their operational and financial functions. This included an assessment of functions related to member experience, medical management, and network contracting.