“They obviously had the knowledge. They are very, very customer focused.”
— [State] Director of Finance for Dept. of Health and Mental Hygiene



  • Develop data warehouse of managed care capitation claims or financial transactions, as well as managed care encounter claims. Request, receive and analyze financial information submitted by managed care organizations.
  • Perform testing and analysis of encounter claims included in the fiscal agent contractor’s Medicaid Management Information System (MMIS) to files maintained by managed care organizations (MCO).
  • Conduct routine meetings with MCOs regarding encounter claim submission issues.
  • Conduct testing and analysis to confirm MCO financial and transactional processes, including testing of subcontractor encounter claim processes for fee‑for‑service and sub-capitation reimbursed services.
  • Perform data mining and analysis on cash disbursement journals submitted by MCOs and subcontractors (delegated vendors).
  • Prepare reports of encounter claim compliance issues with details of completeness and accuracy of encounters.
  • Test compliance of MCOs to regulations and contract requirements.
  • Provide assistance for developing and confirming compliance with corrective action plans and sanctions imposed on MCOs
  • Perform analysis and audit of utilization rates (e.g., immunization, screenings, etc).
    • Operational review of the process used by health plans to aggregate and tabulate encounter data.
    • Comparison of encounter claims to the content of patient medical charts to examine whether data reported on the claim was accurately reflected in the patient medical record.
    • Analysis and comparison of health plans from other states.
  • Perform analysis of contractual standards, industry best practices, National Committee for Quality Assurance (NCQA) standards, Healthcare Effectiveness Data and Information Set (HEDIS) measures and other accepted protocols. Conduct on-site assessments of the health plans’ functions for encounter claims. Assist states in developing corrective action plans and/or contractual sanctions to cure deficiencies in MCO operations, and monitor compliance and correction of deficiencies.


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