Payer Shines in CMS Program Audit with Help from Government Health Plan Audit Services

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Averaging more than 15 years of experience in the healthcare industry, our consultants have worked in a variety of management positions within commercial and government payer organizations, so we understand first-hand your challenges—including competitive pressures, organizational obstacles, and limited resources.

 

Case Overview

Following a core-system replacement project, a not-for-profit health plan based in the Mountain Region, which has been a longstanding client of Change Healthcare Consulting, discovered their provider data was neither correct nor being properly maintained. With this problem stemming across many critical IT and operational systems (UM, Claims, etc.), the client asked the Change Healthcare Consulting team to help them complete a root cause analysis, as well as correct all identified issues.

Solutions

The team spent the beginning of the project creating detailed documentation for the customer’s provider network and structure, change processes, and comprehensive system network and contract descriptions. After the documentation existed, the team developed a process for team members to follow once data errors were discovered. As part of this process, trainings were held with specific team members to support compliance. After a few ups and downs, the impacted team members bought into the new process and the new process resulted in increased productivity and reduced manual workarounds.

Results

Over the course of the engagement, Change Healthcare Consulting led the effort in the cleanup of 2,000+ data errors. The consulting team also provided the client with a final policy and procedure (P&P) document to ensure the developed process lived on in perpetuity. The P&P document completed an open, correctiveaction audit and outlined continued maintenance policies the customer can follow to ensure their best practices continue forward.

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