Medicaid Health Plans

Connolly Healthcare assists Medicaid payers with program integrity and the recovery of improper claim payments. Our professionals are highly skilled at recovering the most money possible across all audit areas while operating with a high sensitivity to providers. Connolly combines advanced technology with a proven audit process to identify and recover overpayments others might miss. We maintain a database of state-by-state Medicaid regulations on notification and collection processes with providers and our auditors refer to this guide during their work. And we conduct root cause analysis and recommend solutions to improve operational efficiencies and reduce the occurrence of future errors.

Below is an overview of just some of the many claim types Connolly will review to identify improper payments in the areas of:

• Member Eligibility Reviews -- Retro-termination
• Coordination of benefits
• Provider billing compliance
• Multiple payments
• Contract compliance
• Medical chart review / hospital bill audit
• Specialty Transplant Audits
• Neonatal -- level of care reviews, transfers, and appropriate coding
• Maternity
• State regulatory and fee schedule audits
• In-patient DRGs (AP & MS-DRG) for potential up-coding. Connolly can reprice and revalidate claims for most states
• Hospital in-patient length of stay for excessive duration, medical necessity, validation, and outlier payments
• Readmissions and transfers for the same or similar DRG (MS-DRG)
• Review of zero paid claims for dually eligible beneficiaries (Medicare and Medicaid) for overpayments that occur when the State Medicaid Program pays the claim but should have been responsible for only the patient’s liability amount
• High-cost injectibles and IV drugs administered in an out-patient or clinic setting
• Duplication and unbundling of services between in-patient and out-patient care settings