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Procuring agile vs.
non-agile
projects in five stages: An overview

By: Naomi Snodgrass,

Jessica Dill is a consultant in BerryDunn’s Government Consulting Group based in our Phoenix office, focusing on state government clients primarily in the Health and Human Services sector. Jessica provides project management and business analysis support to various client projects including options analysis, system planning and procurement.

Jessica Dill
05.30.19

Editor’s note: If you are a state government CFO, CIO, project or program manager, this blog is for you.

What is the difference in how government organizations procure agile vs. non-agile information technology (IT) services? (Learn more about agile here).

In each case, they typically follow five stages through the process as shown in Figure A:
 

Figure A: Overview of Procurement Process for Agile vs. Non-Agile IT Services

However, there are differences in how these stages are carried out if procuring agile vs. non-agile IT services. 

Unfortunately, most government organizations are unaware of these differences, which could result in unsuccessful procurements and ultimately not meeting your project’s needs and expectations. 
This blog series will illustrate how to strategically adjust the standard stages outlined in Figure A to successfully procure agile IT services.

Stage 1: Plan project
In Stage 1, you define the scope of the project by identifying what your organization wants, needs, and can achieve within the available timeframe and budget. You then determine the project’s objectives while strategically considering their impact on your organization before developing the RFP. Figure B summarizes the key differences between the impacts of agile vs. non-agile services to consider in this stage.


Figure B: Plan Project for Agile vs. Non-Agile IT Services

The nuances of planning for agile services reflect an organization’s readiness for a culture shift to a continuous process of development and deployment of software and system updates. 

Stage 2: Draft RFP
In Stage 2, as part of RFP drafting, define the necessary enhancements and functionality needed to achieve the project objectives determined in Stage 1. You then translate these enhancements and functionalities into business requirements. Requirement types might include business needs as functionality, services, staffing, deliverables, technology, and performance standards. Figure C summarizes the key differences between drafting the RFP for a project procuring agile vs. non-agile services.


Figure C: Draft RFP for Agile vs. Non-Agile IT Services

In drafting the RFP, the scope of work emphasizes expectations for how your team and the vendor team will work together, the terms of how progress will be monitored, and the description of requirements for agile tools and methods.

Stage 3: Issue RFP
In Stage 3, issue the RFP to the vendor community, answer vendor questions, post amendments, and manage the procurement schedule. Since this stage of the process requires you to comply with your organization’s purchasing and procurement rules, Figure D illustrates very little difference between issuing an RFP for a project procuring agile or non-agile services.


Figure D: Issue RFP for Agile vs. Non-Agile IT Services 

Stage 4: Review proposals
In Stage 4, you evaluate vendor proposals against the RFP’s requirements and project objectives to determine the best proposal response. Figure E summarizes the key differences in reviewing proposals for a project that is procuring agile vs. non-agile services.


Figure E: Reviewing Proposals for Agile vs. Non-Agile IT Services 

Having appropriate evaluation priorities and scoring weights that align with how agile services are delivered should not be under-emphasized. 

Stage 5: Award and implement contract
In Stage 5, you award and implement the contract with the best vendor proposal identified during Stage 4. Figure F summarizes the key differences in awarding and implementing the contract for agile vs. non-agile services.


Figure F:  Award and Implement Contract for Agile vs. Non-Agile Services 

Due to the iterative and interactive requirements of agile, it is necessary to have robust and frequent collaboration among program teams, executives, sponsors, and the vendor to succeed in your agile project delivery.

What’s next?
The blog posts in this series will explain step-by-step how to procure agile services through the five stages, and at the series conclusion, your organization will better understand how to successfully procure and implement agile services. If you have questions or comments, please contact our team.  

Related Professionals

Editor’s note: If you are a state government CFO, CIO, project or program manager, this blog is for you. 

This is the second blog post in the blog series: “Procuring Agile vs. Non-Agile Service”. Read the first blog. This blog post demonstrates the differences in Stage 1: Plan Project in the five stages of procuring agile vs. non-agile services.

Overview of Procurement Process for Agile vs. Non-Agile IT Services

What is important to consider in agile procurement?

Here are some questions that can help focus the planning for procurement of IT services for agile vs. non-agile projects.

Plan Project Considerations for Agile vs. Non-Agile IT Services

Why are these considerations important?

When you procure agile IT services, you can define the scope of your procurement around a vision of what your organization intends to become, as opposed to being restricted to an end-date for a final delivery.

In an agile project, you get results iteratively; this allows you to constantly reassess requirements throughout the project, including the project plan, the guiding principles, and the project schedule. Your planning is not restricted to considering the effect of one big result at the end of the project schedule. Instead, your plan allows for sequencing of changes and improvements that best reflect the outcomes and priorities your organization needs

Since planning impacts the people-aspect of your strategy, it is important to consider how various teams and stakeholders will provide input, and how you will make ongoing communication updates throughout the project. With an agile procurement project, your culture will shift, and you will need a different approach to planning, scheduling, communicating, and risk management. You need to communicate daily, allowing for reviewing and adjusting priorities and plans to meet project needs. 

How do you act on these considerations?

A successful procurement plan of agile IT services should include the following steps:

  1. Develop a project charter and guiding principles for the procurement that reflect a vision of how your organization’s teams will work together in the future
  2. Create a communication plan that includes the definition of project success and communicates project approach
  3. Be transparent about the development strategy, and outline how iterations are based on user needs, that features will be re-prioritized on an ongoing basis, and that users, customers, and stakeholders are needed to help define requirements and expected outcomes
  4. Provide agile training to your management, procurement, and program operation teams to help them accept and understand the project will present deliverables in iterations, to include needed features, functionality and working products
  5. Develop requirements for the scope of work that align with services and outcomes you want, rather than documented statements that merely map to your current processes 

What’s next? 

Now that you have gained insight into the approach to planning an agile project, consider how you may put this first stage into practice in your organization. Stay tuned for guidance on how to execute the second stage of the procurement process—how to draft the RFP. Our intention is that, following this series, your organization will better understand how to successfully procure and implement agile services. If you have questions or comments, please contact our team.
 

Blog
Plan agile projects: Stage 1

Phew! We did it—The Medicaid Enterprise Systems Conference (MESC) 2019 is one for the books! And, it was a great one. Here is my perspective on objectives and themes that will guide our work for the year.

Monday 

My day started in the fog—I live on an island in Maine, take a boat to get into Portland, and taxi to the airport. Luckily, I got to Portland, and, ultimately Chicago, on time and ready to go. 

Public Sector Technology Group (PSTG) meeting

At the PSTG meetings, we reviewed activities from the previous year and did some planning for the coming year. Areas for consideration included:

  • Modernization Schedule
  • Module Definitions
  • Request for Proposal (RFP) Requirements
  • National Association of State Procurement Officers

Julie Boughn, Centers for Medicare and Medicaid (CMS) Director, Data and Systems Group (DSG) introduced her new boss, Karen Shields, who is the Deputy Director for the Center for Medicaid and CHIP Services (CMCS) within CMS. Karen shared her words of wisdom and encouragement with us, while Julie reminded us that being successful in our work is about the people. CMS also underscored the goal of speeding up delivery of service to the Medicaid program and asking ourselves: “What is the problem we are trying to resolve?” 

CMS’ “You be the State” officer workshop

Kudos to CMS for creating this open environment of knowledge sharing and gathering input.  Areas for discussion and input included:

  • APD Processes
  • Outcomes-Based Certification
  • Increasing and Enhancing Accountability

Tuesday
Opening Plenary

I was very touched by the Girls Inc. video describing the mission of Girls Inc. to inspire girls to be strong, smart, and bold. With organizations like this, and our awareness and action, I am optimistic for the future. Thank you to NESCSO for including this in their opening program.

John Doerr, author of Measure What Matters: OKRs: The Simple Idea that Drives 10x Growth and famed investor, shared his thoughts on how to create focus and efficiency in what we do. Julie’s interview with him was excellent, and I appreciated how John’s Objectives and Key Results (OKR) process prompted Julie to create objectives for what we are trying to do. The objectives Julie shared with us:

  • Improve the quality of our services for users and other stakeholders 
  • Ensure high-quality data is available to manage the program and improve policy making 
  • Improve procurement and delivery of Medicaid technology projects

Sessions

The sessions were well attended and although I can't detail each specific session I attended, I will note that I did enjoy using the app to guide me through the conference. NESCSO has uploaded the presentations. 

Auxiliary meetings

Whether formal or informal, meetings are one of the big values of the conference—relationships are key to everyone’s success, and meeting with attendees in one-on-one environments was incredibly productive. 

Poster session

The poster sessions were excellent. States are really into this event, and it is a great opportunity for the MESC community to engage with the states and see what is going on in the Medicaid Enterprise space.

Wednesday

Some memorable phrases heard in the sessions:

  • Knowledge is power only if you share it
  • We are in this together and want the same outcomes, so let’s share more
  • Two challenges to partnering projects—the two “P”s—are purchasing and personnel
  • Don’t let perfection be the enemy of the good
  • Small steps matter
  • Sharing data is harder than it needs to be—keep in mind the reason for what you are doing

Our evening social event was another great opportunity to connect with the community at MESC and the view of Chicago was beautiful.

Julie Boughn challenged us to set a goal (objective) in the coming year, and, along with it, to target some key results in connection with that goal. Here are some of her conference reflections:

  • Awesome
    • Several State Program and Policy leaders participated at MESC—impressed with Medicaid Director presence and participation
    • Smaller scoped projects are delivering in meeting the desired improved speed of delivery and quality
    • Increased program-technology alignment
  • Not so awesome
    • Pending state-vendor divorces
    • Burden of checklists and State Self-Assessments (SS-As)—will have something to report next year
    • There are still some attempts at very large, multi-year replacement projects—there is going to be a lot of scrutiny on gaining outcomes. Cannot wait five years to change something.

OKRs and request for states and vendors

  • Objective: Improve the quality of services for our users and other stakeholders
    • Key Result (KR): Through test results and audits, all States and CMS can state with precision, the overall accuracy of Medicaid eligibility systems.
    • KR: 100% of State electronic visit verification (EVV) systems are certified and producing annual performance data.
    • KR: 100% of States have used CMS-required testing guidance to produce testing results and evidence for their eligibility systems.
  • Objective: Ensure high-quality data is available to manage the program and improve policy making
    • KR: Transformed Medicaid Statistical Information System (T-MSIS) data is of sufficient quality that it is used to inform at least one key national Medicaid policy decision that all states have implemented.
    • KR:  Eliminate at least two state reporting requirements because T-MSIS data can be used instead.
    • KR: At least five states have used national or regional T-MSIS data to inform their own program oversite and/or policy-making decisions.
  • Objective: Improve how Medicaid technology projects are procured and delivered
    • KR: Draft standard language for outcomes metrics for at least four Medicaid business areas.
    • KR:  Five states make use of the standard NASPO Medicaid procurement.
    • KR:  CMS reviews of RFPs and contracts using NASPO vehicle are completed within 10 business days.
    • KR:  Four states test using small incremental development phases for delivery of services.
  • Request: Within 30 days, states/vendors will identify at least one action to take to help us achieve at least one of the KRs within the next two years.

Last thoughts

There is a lot to digest, and I am energized to carry on. There are many follow-up tasks we all have on our list. Before we know it, we’ll be back at next year’s MESC and can check in on how we are doing with the action we have chosen to help meet CMS’s requirements. See you in Boston!

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MESC 2019―Reflections and Daily Recap

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer—or if you work on a State Medicaid Enterprise System (MES) certification effort.

Measuring performance of Medicaid Enterprise Systems (MES) is emerging as the next logical step in moving Medicaid programs toward modularity. As CMS continues to refine and implement outcomes-based modular certification, it is critical that states adapt to this next step in order to continue to meet CMS funding requirements.

This measurement, in terms of program outcomes, presents a unique set of challenges, many of which a state may not have considered before. A significant challenge is determining how and where to begin measuring program outcomes―to meet it, states can leverage a trusted, independent partner as they undertake an outcomes-based effort.

Outcomes-based planning can be thought of as a three-step process. First, and perhaps most fundamental, is to define outcomes. Second, you need to determine what measurements will demonstrate progress toward achieving those outcomes. And the final step is to create reporting measurements and their frequency. Your independent partner can help you answer these critical questions and meet CMS requirements efficiently by objectively guiding you toward realizing your goals.

  1. Defining Outcomes
    When defining an outcome, it is important to understand what it is and what it isn’t. An outcome is a benefit or added value to the Medicaid program. It is not an output, which is a new or enhanced function of a new MES module. An output is the product that supports the outcome. For example, the functionality of a new Program Integrity (PI) module represents an output. The outcome of the new PI module could be that the Medicaid program continuously improves based on data available because of the new PI module. Some outcomes may be intuitive or obvious. Others may not be as easy to articulate. Regardless, you need to direct the focus of your state and solution vendor teams on the outcome to uncover what the underlying goal of your Medicaid program is.
     
  2. Determining Measurements
    The second step is to measure progress. Well-defined Key Performance Indicators (KPIs) will accurately capture progress toward these newly defined outcomes. Your independent partner can play a key role by posing questions to help ensure the measurements you consider align with CMS’ goals and objectives. Additionally, they can validate the quality of the data to ensure accuracy of all measurements, again helping to meet CMS requirements.
     
  3. Reporting Measurements
    Finally, your state must decide how―and how often―to report on outcomes-based measurements. Your independent partner can collaborate with both your state and CMS by facilitating conversations to determine how you should report, based on a Medicaid program’s nuances and CMS’ goals. This can help ensure the measurements (and support information) you present to CMS are useful and reliable, giving you the best chance for attaining modular certification.

Are you considering an outcomes-based CMS modular certification, or do you have questions about how to best leverage an independent partner to succeed with your outcomes-based modular certification effort? BerryDunn’s extensive experience as an independent IV&V and Project Management Office (PMO) partner includes the first pilot outcomes-based certification effort with CMS. Please visit our IV&V and certification experts at our booth at MESC 2019 or contact our team now.

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Three steps to measure Medicaid Enterprise Systems outcomes

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer.

As CMS moves away from the monolithic Medicaid Management Information System (MMIS) toward an outcomes-based approach that includes a modular Medicaid Enterprise System (MES), there is now more emphasis on system integration (SI). 

In the August 16, 2016 letter, State Medicaid Director (SMD) #16-010, CMS clarified the role of the system integrator (SI) by stating:

CMS envisions a discrete role for the system integrator (SI) in each state, with specific focus on ensuring the integrity and interoperability of the Medicaid IT architecture and cohesiveness of the various modules incorporated into the Medicaid enterprise. 

While the importance of the SI role is apparent, not all states have the resources to build the SI capability within their own organizations. Some state Medicaid IT teams try to solve this by delegating management roles to vendors or contractors. This approach has various risks. A state could lose:

  • Institutional knowledge, as vendors and contractors transition off the project
  • Control of governance, oversight, and leadership
  • The ability to enforce contractual requirements across each vendor, especially the SI

In addition, the ramifications of loss of state accountability can have wide-reaching implementation, operational, and financial impacts, including:

  • The loss of timely decision making, causing projects to fall behind schedule
  • State-specific policy needs not being met, impacting how the MMIS functions in production 
  • Poor integration into the state-specific Operation and Maintenance (O&M) support model, increasing the state’s portion of long-term O&M costs
  • Inefficient and ineffective contract management of each module vendor and contractor (including the SI), possibly leading to unneeded change requests and cost overruns
  • Lack of coordination with the state’s business or IT roadmap initiatives (i.e., system consolidation or cloud migration vendor/approach), possibly leading to rework and missed opportunities to reduce cost or improve interoperability 

Apply strong governance and IV&V to tackle risks

Because the SI vendor is responsible for the integration of multiple modules across multiple vendors, you may consider delegating oversight of module vendors to the SI vendor. 

The major benefit states get from using the SI vendor is efficiency. Having your vendor as the central point of contact can quickly resolve technical issues, while allowing easy coordination of project tasks across each module vendor on a continual basis. 

If you choose to use a vendor for the SI role, establish safeguards and governance to make sure your goals are being met:

  • Build a project-specific governance model (executive committee [EC]) to oversee the vendors and the project
  • Establish a regular meeting cadence for the EC to allow for status updates on milestones and discuss significant project risks and issues 
  • Allocate state resources into project leadership roles (i.e., project manager, vendor contract manager, security lead, testing/Quality Assurance lead, etc.)
  • Conduct regular (weekly) SI status meetings to track progress and address risks and issues 

You also need a strong, involved governance structure that includes teams of state senior leadership, state program managers, SI vendor engagement/contract managers, and Independent Verification and Validation (IV&V) vendors. By definition, one responsibility of IV&V is to identify and monitor project risks and issues that could arise from a lack of independence. 

Your governance teams can debate decisions and disputes, risks and issues, and federal compliance issues with their vendors to define direction and action plans. However, a state representative within these teams should always make the final management decisions, approve all SI scope items and changes, and approve all contractual deliverables from each vendor or contractor.

Your state staff (business and IT) provides project management decision, business needs, requirements (functional and non-functional), policy guidance, and continuity as the vendors and/or contractors change over time. 

The conclusion? In order to be successful, you must retain certain controls and expertise to deploy and operate a successful MMIS system. Our consultants understand the need to keep you in control of managing key portions of implementation projects/programs and operational tasks. If you have questions, please contact BerryDunn’s Medicaid team.  
 

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Risks when using vendors to manage Medicaid system implementation projects

Read this if you are a state Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, State Procurement Officer, or work in a State Medicaid Program Integrity Unit.

The Centers for Medicare & Medicaid Services (CMS) issued a Payment Error Rate Measurement (PERM) Final Rule on July 5, 2017, that made several changes to the PERM requirements. One important change was the updates to the Medicaid Eligibility Quality Control (MEQC) requirement. 

The Final Rule restructures the MEQC program into a pilot program that requires states to conduct eligibility reviews during the two years between PERM cycles. CMS has also introduced the potential for imposing disallowances or reductions in federal funding percentage (FFP) as a result of PERM eligibility error rates that do not meet the national standard. One measure states can use to lessen the chance of this happening is by successfully carrying out the requirements of the MEQC pilot. 

What states should know―important points to keep in mind regarding MEQC reviews:

  • Each state must have a team in place to conduct MEQC reviews. The individuals responsible for the MEQC reviews and associated activities must be separate from the state agencies and personnel responsible for Medicaid and Children’s Health Insurance Program (CHIP) policy and operations, including eligibility determinations.
  • States can apply for federal funding to help cover the costs of the MEQC activities. CMS encourages states to partner with a contractor in conducting the MEQC reviews.
  • The deadline to submit the state planning document to CMS is November 1 following the end of your state’s PERM cycle. If you are a Cycle 2 state, your MEQC planning document is due by November 1, 2019. 
  • If you are a Cycle 1 state, you are (or should be) currently undergoing the MEQC reviews.
  • There are minimum sample size requirements for the MEQC review period: 400 negative cases and 400 active cases (consisting of both Medicaid and CHIP cases) over a period of 12 months.
  • Upon conclusion of all MEQC reviews, states must submit a final findings report along with a corrective action plan that addresses all error findings identified during the MEQC review period.

CMS encourages states to utilize federal funding to carry out and fulfill MEQC requirements. BerryDunn has staff with experience in preparing Advanced Planning Documents (APD) and can assist your state in submitting an APD request to CMS for these MEQC activities. 

Check out the previously released blog, “PERM: Prepared or Not Prepared?” and stay tuned for upcoming blogs about specific PERM topics, including the financial impacts of PERM, and how each review phase will affect your state.   

For questions or to find out more, contact the team

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PERM: Does MEQC affect states?

Read this if you are a state Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer.

When I was growing up, my dad would leave the Bureau of Motor Vehicles or hang up the phone after talking with the phone company and say sarcastically, “I’m from the government (or the phone company) and I’m here to help you. Yeah, right.” I could hear the frustration in his voice. As I’ve gotten older, I understand the hassle of dealing with bureaucracy, where the red tape can make things more difficult than they need to be, and where customers don’t come first. It doesn’t have to be that way.

In my role performing Independent Verification and Validation (IV&V) at BerryDunn, I hear the same skepticism in the voices of some of my clients. I can hear them thinking, “Let me get this straight… I’m spending millions of dollars to replace my old Medicaid Management Information System (MMIS), and the Centers for Medicare and Medicaid Services (CMS) says I have to hire an IV&V consultant to show me what I am doing wrong? I don’t even control the contract. You’re here to help me? Yeah, right.” Here are some things to assuage your doubt. 

Independent IV&V―what they should do for you and your organization

An independent IV&V partner that is invested in your project’s success can:

  • Enhance your system implementation to help you achieve compliance
  • Help you share best practice experience in the context of your organization’s culture to improve efficiency in other areas
  • Assist you in improving your efficiency and timeliness with project management capabilities.

Even though IV&V vendors are federally mandated from CMS, your IV&V vendor should also be a trusted partner and advisor, so you can achieve compliance, improve efficiency, and save time and effort. 

Not all IV&V vendors are equal. Important things to consider:

Independence―independent vendors are a good place to start, as they are solely focused on your project’s success. They should not be selling you software or other added services, push vendor affiliations, or rubber stamp CMS, nor the state. You need a non-biased sounding board, a partner willing to share lessons learned from experience that will help your organization improve.

Well-rounded perspective―IV&V vendors should approach your project from all perspectives. A successful implementation relies on knowledge of Medicaid policy and processes, Medicaid operations and financing, CMS certification, and project management.

“Hello, we are IV&V from BerryDunn, and we are here to help.”

BerryDunn offers teams that consist of members with complementary skills to ensure all aspects of your project receive expert attention. Have questions about IV&V? Contact our team.
 

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We're IV&V and we are here to help you improve your Medicaid organization

Federal contractors with the Centers for Medicare & Medicaid Services (CMS) have begun performing Payment Error Rate Measurement (PERM) reviews under the Final Rule issued in July 2017—a rule that many states may not realize could negatively impact their Medicaid budgets.

PERM is a complex process—states must focus on several activities over a recurring three-year period of time—and states may not have the resources needed to make PERM requirements a priority. However, with the Final Rule, this PERM eligibility review could have financial implications. 

After freezing the eligibility measurement for four years while undergoing pilot review, CMS has established new requirements for the eligibility review component and made significant changes to the data processing and medical record review components. As part of the Final Rule, CMS may implement reductions in the amount of federal funding provided to a state’s Medicaid and Children’s Health Insurance Program (CHIP) programs based on the error rates identified from the eligibility reviews. 

Since the issuance of the Final Rule in July 2017, Cycle 1 states are the first group of states to undergo a PERM cycle, including reviews of the data processing, medical record, and eligibility components. These states are wrapping up the final review activities, and Cycle 2 states are in the early stages of their PERM reviews.

How can your state prepare?

Whether your state is a Cycle 1, Cycle 2, or Cycle 3 state, there are multiple activities your Medicaid departments should engage in throughout each three-year period of time during and between PERM cycles: 

  • Analyzing prior errors cited or known issues, along with the root cause of the error
  • Identifying remedies to reduce future errors
  • Preparing and submitting required questionnaires and documents to the federal contractors for an upcoming review cycle
  • Assisting federal contractors with current reviews and findings
  • Preparing for and undergoing Medicaid Eligibility Quality Control (MEQC) planning and required reviews
  • Corrective action planning

Is your state ready?

We’ve compiled a few basic questions to gauge your state’s readiness for the PERM review cycle:

  • Do you have measures in place to ensure all eligibility factors under review are identifiable and that all federal and state regulations are being met? The eligibility review contractor (ERC) will reestablish eligibility for all beneficiaries sampled for review. This process involves confirming all verification requirements are in the case file, income requirements are met, placement in an accurate eligibility category has taken place, and the timeframe for processing all determinations meets federal and state regulations. 
  • Do you have up-to-date policy and procedures in place for determining and processing Medicaid or CHIP eligibility of an individual? Ensuring eligibility policies and procedures meet federal requirements is just as important as ensuring the processing of applications, including both system and manual actions, meet the regulations. 
  • Do you have up-to-date policy, procedures, and system requirements in place to ensure accurate processing of all Medicaid/CHIP claims? Reviewers will confirm the accuracy of all claim payments based on state and federal regulations. Errors are often cited due to the claims processing system allowing claims to pay that do not meet regulations.
  • Do you have a dedicated team in place to address all PERM requirements to ensure a successful review cycle? This includes staff to answer questions, address review findings, and respond to requests for additional information. During a review cycle, the federal contractors will cite errors based on their best understanding of policies and/or ability to locate required documentation. Responding to requests for information or reviewing and responding to findings in a timely manner should be a priority to ensure accurate findings. 
  • Have you communicated all PERM requirements and updates to policy changes to all Medicaid/CHIP providers? Providers play two integral roles in the success of a PERM review cycle. Providers must understand all claims submission requirements in order to accurately submit claims. Additionally, the medical record review component relies on providers responding to the request for the medical records on a sampled claim. Failure to respond will result in an error. Therefore, states must maintain communication with providers to stress the importance of responding to these requests.
  • Have you begun planning for the MEQC requirement? Following basic requirements identified by CMS during your state’s MEQC period, your state must submit a case planning document to CMS for approval prior to the MEQC review period. After the MEQC review, your state should be prepared to issue findings reports, including a corrective action plan as it relates to MEQC findings.

Need help piloting your state’s PERM review process?

BerryDunn has subject matter experts experienced in conducting PERM reviews, including a thorough understanding of all three PERM review components—eligibility, data processing, and medical record reviews. 

We would love to work with your state to see that measures are in place that will help ensure the lowest possible improper payment error rate. Stay tuned for upcoming blogs where we will discuss other PERM topics, including MEQC requirements, the financial impacts of PERM, and additional details related to each phase of PERM. For questions or to find out more, please email me
 

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PERM: Prepared or not prepared?

As the Project Management Body of Knowledge® (PMBOK®) explains, organizations fall along a structure and reporting spectrum. On one end of this spectrum are functional organizations, in which people report to their functional managers. (For example, Finance staff report to a Finance director.) On the other end of this spectrum are projectized organizations, in which people report to a project manager. Toward the middle of the spectrum lie hybrid—or matrix—organizations, in which reporting lines are fairly complex; e.g., people may report to both functional managers and project managers. 

Problem: Weak Matrix Medicaid System Vendors

This brings us to weak matrix organizations, in which functional managers have more authority than project managers. Many Medicaid system vendors happen to fall into the weak matrix category, for a number of different reasons. Yet the primary factor is the volume and duration of operational work—such as provider enrollment, claims processing, and member enrollment—that Medicaid system vendors perform once they exit the design, development, and implementation (DDI) phase.

This work spans functional areas, which can muddy the reporting waters. Without strong and clear reporting lines to project managers, project success can be seriously (and negatively) affected if the priorities of the functional leads are not aligned with those of the project. And when a weak matrix Medicaid system vendor enters a multi-vendor environment in which it is tasked with implementing a system that will serve multiple departments and bureaus within a state government, the reporting waters can become even muddier.


Solution: Using a Project Management Office (PMO) Vendor

Conversely, consulting firms that provide Project Management Office (PMO) services to government agencies tend to be strong matrix organizations, in which project managers have more authority over project teams and can quickly reallocate team members to address the myriad of issues that arise on complex, multi-year projects to help ensure project success. PMOs are also typically experienced at creating and running project governance structures and can add significant value in system implementation-related work across government agencies.

Additional benefits of a utilizing a PMO vendor include consistent, centralized reporting across your portfolio of projects and the ability to quickly onboard subject matter expertise to meet program and project needs. 
For more in-depth information on the benefits of using a PMO on state Medicaid projects, stay tuned for my second blog in this series. In the meantime, feel free to send your PMO- or Medicaid-related questions to me
 

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The power of the PMO: Fixing the weak matrix

As your organization works to modernize and improve your Medicaid Enterprise System (MES), are you using independent verification and validation (IV&V) to your advantage? Does your relationship with your IV&V provider help you identify high-risk project areas early, or provide you with an objective view of the progress and quality of your MES modernization initiative? Maybe your experience hasn’t shown you the benefits of IV&V. 

If so, as CMS focuses on quality outcomes, there may be opportunities for you to leverage IV&V in a way that can help advance your MES to increase the likelihood of desired outcomes for your clients. 

According to 45 Code of Federal Regulations (CFR) § 95.626, IV&V may be required for Advanced Planning Document (APD) projects that meet specific criteria. That said, what is the intended role and benefit of IV&V? 

To begin, let’s look at the meaning of “verification” and “validation.” The Institute of Electrical and Electronics Engineers, Inc. (IEEE) Standard for Software Verification and Validation (1012-1998) defines verification as, “confirmation of objective evidence that the particular requirements for a specific intended use are fulfilled.” Validation is “confirmation of objective evidence that specified requirements have been fulfilled.” 

Simply put, verification and validation ensure the right product is built, and the product is built right. 
As an independent third party, IV&V should not be influenced by any vendor or software application. This objectivity means IV&V’s perspective is focused on benefiting your organization. This support includes: 

  • Project management processes and best practices support to help increase probability of project success
  • Collaboration with you, your vendors, and stakeholders to help foster a positive and efficient environment for team members to interact 
  • Early identification of high-risk project areas to minimize impact to schedule, cost, quality, and scope 
  • Objective examination of project health in order for project sponsors, including the federal government, to address project issues
  • Impartial analysis of project health that allows state management to make informed decisions 
  • Unbiased visibility into the progress and quality of the project effort to increase customer satisfaction and reduce the risk and cost of rework
  • Reduction of errors in delivered products to help increase productivity of staff, resulting in a more efficient MES 

Based on our experience, when a trusted relationship exists between state governments and IV&V, an open, collaborative dialogue of project challenges—in a non-threatening manner—allows for early resolution of risks. This leads to improved quality of MES outcomes.    

Is your IV&V provider helping you advance the quality of your MES? Contact our team.

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Leveraging IV&V to achieve quality outcomes

Truly effective preventive health interventions require starting early, as evidenced by the large body of research and the growing federal focus on the role of Medicaid in addressing Social Determinants of Health (SDoH) and Adverse Childhood Experiences (ACEs).

Focusing on early identification of SDoH and ACEs, CMS recently announced its Integrated Care for Kids (InCK) model and will release the related Notice of Funding Opportunity this fall.

CMS describes InCK as a child-centered approach that uses community-based service delivery and alternative payment models (APMs) to improve and expand early identification, prevention, and treatment of priority health concerns, including behavioral health issues. The model’s goals are to improve child health, reduce avoidable inpatient stays and out-of-home placement, and create sustainable APMs. Such APMs would align payment with care quality and support provider/payer accountability for improved child health outcomes by using care coordination, case management, and mobile crisis response and stabilization services.

State Medicaid agencies have many things to consider when evaluating this funding opportunity. Building on current efforts and innovations, building or leveraging strong partnerships with community organizations, incentivizing evidence-based interventions, and creating risk stratification of the target population are critical parts of the InCK model. Here are three additional areas to consider:

1. Data. States will need information for early identification of children in the target population. State agencies?like housing, justice, child welfare, education, and public health have this information?and external organizations—such as childcare, faith-based, and recreation groups—are also good sources of early identification. It is immensely complicated to access data from these disparate sources. State Medicaid agencies will be required to support local implementation by providing population-level data for the targeted geographic service area.

  • Data collection challenges include a lack of standardized measures for SDoH and ACEs, common data field definitions, or consistent approaches to data classification; security and privacy of protected health information; and IT development costs.
  • Data-sharing agreements with internal and external sources will be critical for state Medicaid agencies to develop, while remaining mindful of protected health information regulations.
  • Once data-sharing agreements are in place, these disparate data sources, with differing file structures and nomenclature, will require integration. The integrated data must then be able to identify and risk-stratify the target population.

For any evaluative approach or any APM to be effective, clear quality and outcome measures must be developed and adopted across all relevant partner organizations.

2. Eligibility. Reliable, integrated eligibility and enrollment systems are crucial points of identification and make it easier to connect to needed services.

  • Applicants for one-benefit programs should be screened for eligibility for all programs they may need to achieve positive health outcomes.
  • Any agency at which potential beneficiaries appear should also have enrollment capability, so it is easier to access services.

3. Payment models. State Medicaid agencies may cover case management services and/or targeted case management as well as health homes; leverage Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services; and modify managed care organization contract language to encourage, incent, and in some cases, require services related to the InCK model and SDoH. Value-based payment models, already under exploration in numerous states, include four basic approaches:

  • Pay for performance—provider payments are tied directly to specific quality or efficiency indicators, including health outcomes under the provider organization’s control. 
  • Shared savings/risk—some portion of the organization’s compensation depends on the managed care entity achieving cost savings for the targeted patient population, while realizing specific health outcomes or quality improvement.
  • Pay for success—payment is dependent upon achieving desired outcomes rather than underlying services.
  • Capitated or bundled payments—managed care entities pay an upfront per member per month lump sum payment to an organization for community care coordination activities and link that with fee-for-service reimbursement for delivering value-added services.

By focusing on upstream prevention, comprehensive service delivery, and alternative payment models, the InCK model is a promising vehicle to positively impact children’s health. Though its components require significant thought, strategy, coordination, and commitment from state Medicaid agencies and partners, there are early innovators providing helpful examples and entities with vast Section 1115 waiver development and Medicaid innovation experience available to assist.

As state Medicaid agencies develop and implement primary and secondary prevention, cost savings can be achieved while meaningful improvements are made in children’s lives.

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Three factors state medicaid agencies should consider when applying for InCK funding

Over the course of its day-to-day operations, every organization acquires, stores, and transmits Protected Health Information (PHI), including names, email addresses, phone numbers, account numbers, and social security numbers.

Yet the security of each organization’s PHI varies dramatically, as does its need for compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Organizations that meet the definition of a covered entity or business associate under HIPAA must comply with requirements to protect the privacy and security of health information.

Noncompliance can have devastating consequences for an organization, including:

  • Civil violations, with fines ranging from $100 to $50,000 per violation
  • Criminal penalties, with fines ranging from around $50,000 to $250,000, plus imprisonment

All it takes is just one security or privacy breach. As breaches of all kinds continue to rise, this may be the perfect time to evaluate the health of your organization’s HIPAA compliance. To keep in compliance and minimize your risk of a breach, your organization should have:

  • An up-to-date and comprehensive HIPAA security and privacy plan
  • Comprehensive HIPAA training for employees
  • Staff who are aware of all PHI categories
  • Sufficiently encrypted devices and strong password policies

HIPAA Health Check: A Thorough Diagnosis

If your organization doesn’t have these safeguards in place, it’s time to start preparing for the worst — and undergo a HIPAA health check.

Organizations need to understand what they have in place, and where they need to bolster their practice. Here are a variety of fact-finding methods and tools we recommend, including (but not limited to):

  • Administrative, technical, and physical risk analyses
  • Policy, procedure, and business documentation reviews
  • Staff surveys and interviews
  • IT audits and testing of data security

Once you have diagnosed your organization’s “as-is” status, you need to move your organization toward the “to-be” status — that is, toward HIPAA compliance — by:

  • Prioritizing your HIPAA security and privacy risks
  • Developing tactics to mitigate those risks
  • Providing tools and tactics for security and privacy breach prevention and minimization
  • Creating or updating policies, procedures, and business documents, including a HIPAA security and privacy plan

As each organization is different, there are many factors to consider as you go through these processes, and customize your approach to the HIPAA-compliance needs of your organization.

The Road to Wellness

An ounce of prevention is worth a pound of cure. Don’t let a security or privacy breach jump-start the compliance process. Reach out to us for a HIPAA health check. Contact us if you have any questions on how to get your organization on the road to wellness.

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How healthy is your organization's HIPAA compliance?

A year ago, CMS released the Medicaid Enterprise Certification Toolkit (MECT) 2.1: a new Medicaid Management Information Systems (MMIS) Certification approach that aligns milestone reviews with the systems development life cycle (SDLC) to provide feedback at key points throughout design, development, and implementation (DDI).

The MECT (recently updated to version 2.2) incorporates lessons learned from pilot certifications in several states, including the successful West Virginia pilot that BerryDunn supported. MECT updates have a direct impact on E&E systems—an impact that may increase in the near future. Here is what you need to know:         

Then: Initial Release

In February 2017, CMS introduced six Eligibility & Enrollment (E&E) checklists. Five were leveraged from the MECT, while the sixth checklist contained unique E&E system functionality criteria and provided a new E&E SDLC that—like the MECT—depicted three milestone reviews and increased the Independent Verification and Validation (IV&V) vendor’s involvement in the checklists completion process.

Now: Getting Started

Completing the E&E checklists will help states ensure the integrity of their E&E systems and help CMS guide future funding. This exercise is no easy task, particularly when a project is already in progress. Completion of the E&E checklists involves many stakeholders, including:

  • The state (likely more than one agency)
  • CMS
  • IV&V
  • Project Management Office (PMO)
  • System vendor(s)

As with any new processes, there are challenges with E&E checklists completion. Some early challenges include:

  • Completing the E&E checklists with limited state project resources
  • Determining applicable criteria for E&E systems, especially for checklists shared with the MMIS
  • Identifying and collecting evidence for iterative projects where criteria may not fall cleanly into one milestone review phase
  • Completing the E&E checklists with limited state project resources
  • Working with the system vendor(s) to produce evidence

What’s Next?

Additionally, working with system vendors may prove tricky for projects that already have contracts with E&E vendors, as E&E systems are not currently subject to certification (unlike the MMIS). This may lead to instances where E&E vendors are not contractually obligated to provide the evidence that would best satisfy CMS criteria. To handle this and other challenges, states should communicate risks and issues to CMS and work together to resolve or mitigate them.

As CMS partners with states to implement the E&E checklists, some questions are expected to be asked. For example, how much information can be leveraged from the MECT, and how much of the checklists completion process must be E&E-specific? Might certification be required in the near future for E&E systems?

While there will be more to learn and challenges to overcome, the first states completing the E&E checklists have an opportunity to lead the way on working with CMS to successfully build and implement E&E systems that benefit all stakeholders.

On July 31, 2017, CMS released the MECT 2.2 as an update to the MECT 2.1.1. As the recent changes continue to be analyzed, what will the impact be to current and future MMIS and E&E projects?

Check back here at BerryDunn Briefings in the coming weeks and we will help you sort it out.

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Check this: CMS checklists aren't just for MMIS anymore.

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