medicaid enterprise systems: procurement, development…
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MEDICAID ENTERPRISE SYSTEMS: PROCUREMENT, DEVELOPMENT, AND INSTALLATIONPRESENTED ON BEHALF OF HSFO
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CONTENTS
PROCUREMENT DESIGN AND DEVELOPMENTINSTALLATION
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CMS’ “NORTH STARTS”
Successful, faster delivery of services to Medicaid programs
Increased competition, lower barriers to vendor changes
Liberate the data!
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PROCUREMENT: MODULARITY
Old Procurement MethodologySingle Vendor—Big Bang Approach
New Procurement MethodologyModularity
Modularity: Big BangAll modules implemented at once and existing system decommissioned
Modularity: GradualModules implemented over time and existing system run in parallel until all modules online
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MODULAR APPROACH TO MEDICAID MANAGEMENT INFORMATION SYSTEMS (MMIS)
ProviderProvider processing, monitors license expiration, renewals, background checks
Claims/ ReferenceProcess FFS and Encounter claims
FinancialProvider and MCO payments, AR/AP and federal claiming
Service AuthService/Prior Authorization for member
MemberInformation such as eligibility, enrollment, spenddown, etc.
Systems IntegratorResponsible for systems talking to each other
Enterprise Data Warehouse (EDW)Analytics and Reporting
Provider EnrollmentEnrolling Providers
Pharmacy Benefit Manager (PBM)Process Drug Claims
TPLThird Party Liability information about members with other insurance
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PROCUREMENT: NASPO
National Association of State Procurement Officers (NASPO)—states are getting together to evaluate modules. Advantages: o States can negotiate with pre-approved vendorso The RFP and all Master Agreements have been approved by CMSo Predefined costs for participating stateso First module was Provider Services, which qualified and pre-approved Six
vendors for Provider Services solutionso Each state shall determine the best fit and best value to meet their business
needso Comprehensive terms and conditions are included in all Master Agreementso Robust Performance Standards are included in all agreementso The RFP included comprehensive requirements to meet Provider Services needso MECT checklist items are mapped to requirements to support CMS certificationo Federally compliant and configurable solutions and agreements to address state
specific laws and policieso Prepared considerations for states executing a Participating Addendum
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DESIGN AND DEVELOPMENT
MaintenanceDeploymentTesting
DevelopmentDesignAnalysis
Waterfall (older approach)All phases of SDLC are performed sequentially in order, completing one before beginning the next phase
System Development Life Cycle (SDLC)
Agile (newer approach)Basically the same phases of the SDLC, just implemented more rapidly and frequently
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INSTALLATION
After Implementation
When you make it to the end
After ModularityWhat comes next?
Paths to Modularity
Big Bang vs. Gradual
Why Modularity?
Failures
Many delays, failures and cost overruns caused
CMS and states to look to different
approaches
Too early to tell if modularity will decrease or
increase risk for states
Big Bang –Implement on
same day
Gradual –Implement over a
longer span of time
Challenging for the first six month,
FFS payments especially
challenging. Have a plan.
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