HMS – A Trusted Partner in Medicaid Program Integrity
For over 25 years, HMS has worked in the Medicaid claiming environment to identify, audit, and recover improper Medicaid payments for both fee-for-service and managed care populations.
We have a deep understanding of how Medicaid programs vary from state to state, and know how to work effectively with carriers, payors, the provider community, MMIS vendors, and other state agencies and stakeholders. We have worked with countless client, payor, and MMIS data file structures to support cost containment and audit projects on behalf of our clients.
Our results speak to the soundness of our approach: as a result of our services, clients recovered over $1.8 billion in 2010, and saved billions of dollars more through prevention of erroneous payments.
What We Offer
HMS’s Medicaid RAC solution is proven and comprehensive.
- Data Analysis. Our data analysis extends to all claim types, including hospital inpatient and outpatient, pharmacy and dental, long term care, home health, hospice facilities, radiology, behavioral health, and other provider types. Our data warehouse holds over 7 billion claims. Our effective data analytics, algorithms, and data processing capabilities help us identify overpaid claims, target potential improper payments, and identify providers for review.
- Audit Services. We perform prospective and retrospective audit services for both Medicaid and Medicare programs. Our depth of experience in both programs enables us to understand the complexities and myriad issues that present substantial obstacles to less experienced vendors–we know how to translate data into solutions and savings.
- Full Spectrum. We examine all claim types, including hospital, medical, pharmacy, long term care, durable medical equipment, and behavioral health claims. We look at each episode of care from every angle, and we understand how eligibility, coverage, utilization, clinical, and financial information can be used together to profile errors and identify potential improper payments.
- Sensitive Recoveries. We have a record of success recovering overpayments from providers. Our collaborative, sensitive approach protects the relationship between our clients and their providers. Our experienced Provider Relations team communicates with providers throughout the recovery process.
- Low Appeal Rate. Our approach, staff, and proactive provider education and communications have resulted in an extraordinarily low rate of appeals, and an equally low rate of overturn for those claims that are appealed.
- Right Resources. We have the tools, processes and personnel necessary to maximize improper payment identification and recovery efforts, and support our clients’ ability to meet all administrative requirements related to appropriate state licensure, solvency, and reporting and compliance with all applicable federal and state laws and regulations.
Our experienced staff includes certified coding professionals, Registered Nurses, and a panel of over 600 peer review physicians and other specialty providers. In particular, our staff knows how to operate within the Medicaid environment, and understands the Medicaid-specific rules that define our client’s RAC programs. - Customized Technology. All of our services, including our proprietary case management system, are supported by custom technology that enables us to coordinate all identification and recovery efforts and ensure efficiency, accuracy, and consistency of results.
HMS’s Integrated Approach Supports
Medicaid RAC Program Requirements
HMS has the resources in place and the breadth and depth of experience required to help state Medicaid agencies realize their full recovery potential, while ensuring maximum efficiency and full compliance with state and federal regulations. Our state-of-the-art technology, effective operational processes, and best practices ensure that Medicaid RAC programs are efficient, minimize provider abrasion, and avoid duplicating other initiatives.
HMS offers innovative, end-to-end cost containment and improper Medicaid payment identification and recovery solutions. Our solutions include data mining, case management, review/audits, cash recovery, cash management and reconciliation.
We understand the full spectrum of Medicaid operations, and leverage the inter-relatedness of coordination of benefits and program integrity services to maximize the identification and recovery of improper payments, while identifying providers, claims, and patterns that may indicate fraud and waste.
Please email us if you would like to speak with us about your Medicaid RAC needs. 
CMS recently selected HMS as a Medicaid Integrity audit contractor under the Medicaid Integrity Program.
