CMS promotes modular solutions for state Medicaid systems (MMIS) to promote reuse among states, minimize customization and increase competition. One customer ran post-adjudicated claims from their mainstream editing software through our Payment Integrity Platform. We found that 70% of those claims still had aberrations.  Had they been corrected prior to payment; the customer would have avoided $ 3 Million a month in errant payments. What if this was happening to your MCO?


Protecting Enrollees at a Reasonable Cost

Payment Integrity and case management are key components of a Comprehensive Medicaid Integrity Plan (CMIP).  Your Medicaid Information Technology Architecture (MITA) needs open, scalable, modularized and best in class analytic solutions to drive integrity.

Context's real-time, cloud based Program Integrity support includes our Payment Integrity Platform and case management extensions:

  • Pricing leveraging UCR and all 16 Medicare Prospective Payment Systems to facilitate price negotiations and integrity checks 
  • Advanced Medicare, Commercial and Medicaid analytics logic to assess payment compliance at a granular level 
  • FWA analytics and reporting at the enrollee and provider levels
  • Case management system extensions to pass potential aberrations detected into a functional workflow system in your SIU
  • Special investigation business partnerships to facilitate rounding out your CMIP if needed