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Please review the official Payment Integrity FWA RFP

Payment Integrity – Fraud Waste and Abuse Request for Proposal

Background 

CenCal Health (CCH) is a Non-Profit Community Based Health Care Organization contracted with the State of California to administer Medi-Cal benefits through local care providers in Santa Barbara and San Luis Obispo counties. We provide health coverage for 1 in 4 people in Santa Barbara County, and 1 in 5 in San Luis Obispo County. We have been in operation since 1983 and are recognized nationally as the oldest Medicaid managed care program of its kind in the country. Our mission is to improve the health and well-being of the communities we serve by providing access to high-quality health services, along with education and outreach for our members. 

Opportunity Description 

CenCal Health is in the market for a collaborative engagement with a vendor offering comprehensive services in Payment Integrity, including Fraud, Waste, and Abuse management. This partnership will be pivotal in the establishment of a solid Payment Integrity Program that integrates extensive Fraud, Waste, and Abuse prevention components. 

CenCal Health is on a quest for a reliable vendor that can deliver first-rate services in the Payment Integrity – Fraud Waste and Abuse sector, thereby enabling the organization to efficiently manage and process claims. 

Currently, CenCal Health provides coverage to approximately 228,679 members under its Medi-Cal program. 

The selection will favor a vendor that not only aligns with but also amplifies our organizational values and mission, contributing significantly to our strategic vision. CenCal Health is eager to find a vendor, or multiple vendors, poised to support and achieve our key strategic goals in this space. 

  • Deliver value through innovation, including innovative payment models with aligned incentives.
  • Provide core competencies in administrative and clinical services including population health management.
  • Achieve and maintain high member and provider satisfaction.
  • Define and monitor quality measures that distinguish true improvement.
  • Establish a strong foundation to ensure long-term success.
  • Be fully invested in working with CenCal Health to develop flexible solutions that meet our business and strategic needs.

The ideal Vendor will provide or arrange for a suite of Payment Integrity – Fraud Waste and Abuse services supported by comprehensive clinical support, claim adjudication, prior authorization (coverage determination) fulfillment, data analysis, and reporting capabilities. This should include both pre & post-pay services for payment integrity, clinical chart reviews (DRG, Short Stay, Readmission), a comprehensive FWA package that includes identification of leads for investigation, robust reporting as well as data mining capabilities, and ideally also include Coordination of Benefits & Other Health Coverage (COB & OHC) verification capabilities.