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Medicaid MCO establishes, manages statewide operations service center

RFP
Medicaid MCO The client
A Medicaid managed care organization (MCO) operating a network of more than 900 providers supports a coverage area that includes approximately 1.4 million individuals, with 225,000 eligible members. The MCO is proud of its long-standing track record of proven success, achieved through a hands-on and compassionate approach that has resulted in significant savings for taxpayers, positive consumer outcomes, and reinvestment in additional services for the communities it serves.

The challenge
The state in which the organization operates is experiencing a period of MCO consolidation, driven in part by the prospect of a statewide managed care expansion. Given the rapidly changing and uncertain regulatory and political environment, the MCO wanted to increase its long-term viability by establishing itself as a market leader in core operations and providing an offering to other plans.  

The Grant Thornton solution
Grant Thornton LLP led an assessment and multiple strategic planning sessions with senior executives, concluding that the establishment of a service center would leverage the organization’s strengths and position it as an integral market player. The organization engaged Grant Thornton as the overarching program manager to help execute this vision.

Our mission was to establish a stand-alone shared service center that would deliver claims, provider contracting and enrollment processing units. To fulfill its purpose, the service center solution focused on sustainability and scalability, allowing for an expansion of operations to support other MCOs looking to make improvements. This service center would fill a need within the state and comply with the requirements of the Affordable Care Act. The plan would focus on cost containment, quality improvement and increased accountability.

Is a service center a viable option for your organization?
- Decentralized or disparate functions
- Inconsistent outcomes for the same functions
- External pressures that may threaten the business model or future sustainability
- Business expansion — sell services to others
- Cost-saving needs
- Merger or acquisition
- Industry consolidation

Grant Thornton professionals worked with the MCO to identify pertinent service center functions, and then performed or managed key tasks and deliverables, resulting in the creation and launch of the service center.

  • Program management — Our team worked with key client-stakeholders to develop a program plan and overall strategy for the establishment of the service center. Key elements of program management included steering and governance meetings, change management and communications, issue and risk resolution, and facility and technical readiness, as well as strategic decision-making.   
  • Functional solution design — To maximize sustainability and standardization, we directed a significant level of effort toward the service center’s functional design. We worked through the entire design process, which included functional splits to confirm the service center’s scope, process maps to illustrate new solutions, and a full suite of procedures outlining both workflow elements and operational standards.   
  • Management functions — To maximize outcomes and drive efficiency, we developed a series of operating and performance metrics, as well as contractual service-level agreements (SLAs) for ongoing measurement of the service center and adherence to contractual obligations. We established reports and processes to measure and act on each identified metric and contractual SLA.   
  • Financial and legal considerations — The team collaborated with the client on a financial analysis and planning framework to ensure the center’s financial viability. This plan also outlined detailed cost allocations, resource needs and pricing options. In addition, we worked closely with the client’s legal team to identify SLAs and necessary provisions for service center customers.
  • Organizational and staffing determinations — We focused on a key element of the success of the service center: people. To support the organization and onboarding, the team designed an organizational plan that included the design and delivery of end-to-end training, as well as plans to support resource expansion.

    Benefits of a service center
    Standardization of documentation and processes

    Consistency in outcomes
    Scalability in staff numbers
    Cost savings from reduced duplication
    Sustainability in business
    Advance mission
The outcome
Grant Thornton managed the establishment of a successful, on-time service center program through all phases, from analysis through implementation. In addition to supporting core operational processes, the team consolidated back-office assets, established a financial framework, and instituted change management processes to allow for easy expansion and onboarding. The service center went live in February 2014 and is well positioned to:

  •  Increase scale and return on assets
  •  Improve performance and operational efficiency
  •  Establish a statewide infrastructure
  •  Standardize functions for corporate, provider and member use
  •  Reduce administrative costs
  •  Ease monitoring burden for state and local agencies

Download the case study (PDF).

Contacts
David Tyler

Partner

Health Care Advisory Services

+1 404 475 0180

Matthew Tabor
Senior Manager
Health Care Advisory Services
+1 404 475 0198