For questions, please contact: Alison Gibbs 617-426-2026 agibbs@pcgus.

com

Medicaid Behavioral Health Agency Audit

PCG Company Background PCG has more than 26 years of experience in behavioral health consulting for state and local governments, reflecting our commitment to quality behavioral health systems. PCG helps clients to develop, improve, and refine their system of services for individuals with mental health and substance abuse challenges and individuals with intellectual and developmental disabilities. In addition to the behavioral health audit services utilized by New Mexico, PCG provides a broad range of services designed to strengthen behavioral health delivery systems including: strategic planning, quality management, rate setting, waiver design and management, and Medicaid rebalancing. PCG and its CEO have been honored by the National Alliance on Mental Illness (NAMI), the Massachusetts Association for Mental Health, and a number of other behavioral health organizations o In the 1990s PCG was a national leader in assisting states to de-institutionalize services for persons with mental illness and establish a comprehensive system of home and community-based care (HCBS). PCG is also a national leader in assisting states to reform programs for students receiving health and mental health services in a school setting. Overall, PCG is a respected leader in health care management consulting for state governments. PCGs mission is to be the market leader in delivering outstanding financial and operational results to health, human services, education, and other government clients. PCG is a leading provider of health care program integrity and operations improvement services as well as a recognized leader in health care reform and Health Insurance Exchange (HIX) planning and implementation

PCG Audit Capabilities PCG has demonstrated audit expertise. Recent examples include: o Oklahoma State Department of Health (OSDH): medical and financial records review of 100 providers that received reimbursement from the states Trauma Fund for services provided. PCG identified 10 percent of reviewed uncompensated trauma care claims submitted by hospitals, physicians, and EMS providers that were not in compliance with the Trauma Funds eligibility criteria. These claims represented over $1M in Trauma Fund payments. o State of Virginia, Department of Medical Assistance Services (DMAS): statewide community behavioral health services post payment reviews, including on-site and desk reviews, July 2009March 2012. More than 100 on-site/desk audits were completed, identifying roughly $25 million in overpayments.

Public Consulting Group, Inc. | 148 State Street, Boston, Massachusetts | www.publicconsultinggroup.com

For questions, please contact: Alison Gibbs 617-426-2026 agibbs@pcgus.com

PCGs auditing experience in North Carolina has been mis-characterized in the media. PCG wishes to clarify a few of the key points: o The focus of the NC State Auditor was our clients administration of our contract not PCGs performance. . PCGs contract in NC does not include responsibility for recouping overpayments. There are many reasons why NC did not recoup on our findings, which was the Auditors focus. As an example, providers go out of business or begin operating under a different corporate name. Nor is it uncommon for overpayment findings to be reduced throughout due process proceedings once providers, facing sanctions, make their records available for review after multiple requests which was the case in NC. o PCGs Overpayment Reviews in NC have resulted in improved management of the program and oversight
of the public purse:

PCG audits have resulted in a 23% improvement in provider compliance between FY11 and FY13 164 abusive providers ceased billing NC Medicaid, rather than pay back the state, following a PCG audit

o The vast majority of PCGs clinical findings are upheld by the NC Department of Health and Human Services (DHHS) during due process. 95% of PCGs final findings (after providers have finally cooperated with multiple record requests) have been upheld by a hearings officer upon appeal New Mexico PCG was contracted by the New Mexico Human Services Department (HSD) to conduct a medical record audit, which differs from the clinical and data analytic reviews conducted by the behavioral health program vendor. PCGs contract is a Time-and-Materials contract. As such, PCG had no financial stake in the outcome of our work. PCG used an audit approach that was developed and refined through its national experience in auditing behavioral health providers and was tailored to NMs payment rules and regulations. The approach included: o Random sampling of provider claims. The sampling methodology allows for a statistically valid extrapolation of the findings. o Consumer case file review. A review of a full years worth of case file notes for selected consumers. Not extrapolated, but can be used to identify deficiencies that cannot be identified when viewing a single claim. PCGs role did not and does not go beyond conducting the audit and providing the findings and recommendations. Actions taken as a result of PCGs findings and recommendations are now in the purview of the Attorney Generals office.
Public Consulting Group, Inc. | 148 State Street, Boston, Massachusetts | www.publicconsultinggroup.com