Medicaid Administrative Claiming

Within the Medicaid program, a cost must be classified as a “service” or “administrative” cost in order for it to be reimbursed to the state or locality that incurs it. The Centers for Medicare and Medicaid Services (CMS) recognize that state Medicaid programs rely on administrative activities that extend beyond the provision of direct services to clients. Individuals and organizations are responsible for locating, coordinating, and monitoring necessary and appropriate services for each Medicaid recipient. Additionally, states must identify and enroll individuals before they can access services. States are required to prepare cost allocation plans in order to quantify the costs of performing these required activities. Because the cost of these activities is often more difficult to quantify than direct service costs, mechanisms such as time studies are essential tools for measuring the level of effort that can be claimed for federal reimbursement.

A key subset of Medicaid administrative is often referred to as “Administrative Case Management” or ACM. ACM is a way to obtain Medicaid administrative reimbursement for case workers that work directly with Medicaid eligible clients.

Specific ACM activities include:

• Medicaid outreach
• Medicaid eligibility determinations
• Referral to services
• Case planning
• Case management
• Development of an individual plan of care
• Case reviews

PCG can assist with determining the impact of new federal regulations and proposed rules on administrative claiming, including how proposed rules on case management may impact existing ACM programs.

PCG Services

PCG offers a number of services to help state agencies ensure compliance with federal regulations and identify opportunities for revenue enhancement. Services include:

• Activity and cost identification
• Federal claiming review
• Cost allocation plan (CAP) review and development
• CAP design, implementation, and management
• Indirect Cost Rate proposal preparation
• Review and development of time study methodologies, including Random Moment Time Studies (RMTS)
• Identification of systems costs and assistance with Advanced Planning Documents (APD)

Click on the image to download our information sheet on this service.