@Regulatory: October 2012
Pharmacy encounter claims data compliance in state Medicaid managed care
The Patient Protection and Affordable Care Act1 (PPACA) has provided Managed Care Organizations (MCOs) with significant opportunities to expand their Medicaid business with state agencies. Even before PPACA, states had been more aggressive in controlling costs by implementing managed care delivery systems for Medicaid benefits for both medical and pharmacy services. With added opportunity, MCOs face added risk as they become more involved in state Medicaid programs. MCOs are exposed to both the compliance and financial risks created by contracting with individual states.
The purpose of this article is to help MCOs understand the financial and compliance risk associated with the pharmacy encounter submission process and to provide potential solutions that will allow MCOs to manage those risks.
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