Maine’s Medicaid Essay Sample

9 September 2017

The province of Maine provides medical coverage for over 260. 000 of its occupants through its Medicaid plan. Healthcare suppliers. including physicians. infirmaries. clinics. and nursing places. submit claims to Medicaid in order to be paid for the services they provide to Medicaid patients. As the 1990s Drew to a stopping point. Maine. like many other provinces. began be aftering for a complete inspection and repair of its Medicaid claims treating systems to follow with the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) . HIPAA was enacted to standardise the direction of patient wellness and records. and. most notably. the protection of patient privateness. HIPAA provided a deadline of October 1. 2002. to run into its patient privateness and security criterions. Maine had to see a figure of factors in add-on to HIPAA in fixing for its systems inspection and repair. The Medicaid plan. as outlined by the federal authorities. was going progressively complex with new services added. each with codifications and subcodes assigned to them. As a consequence. payments to suppliers were broken down into smaller and more legion pieces.

The province besides wanted to offer suppliers entree to patient eligibility and claim position informations online in the hopes of cut downing the volume of calls to the province Bureau of Medical Services. which ran Medicaid under the Department of Human Services ( DHS ) . At the clip. Maine was treating over 100. 000 Medicaid claims per hebdomad on a Honeywell mainframe that dated back to the seventiess. The system was non capable of back uping HIPAA demands or the on-line entree that the province wished to implement. The state’s IT section decided that a wholly new system would be more cost-efficient and easier to keep than an ascent of the old system. This attack contrasted with what some other provinces had done. Nearby Massachusetts. for case. take to deploy a Web portal as an incorporate front terminal to its bing bequest systems. However. the IT staff at the DHS believed a new made-to-order system it would be more flexible because they could do it rule-based in order to suit frequent alterations in Medicaid regulations. The IT staff besides rejected an option to outsource claims treating systems to a service supplier such as Electronic Data Systems ( EDS ) .

For such a big and important undertaking. the DHS enlisted a private contractor to work with its IT staff. The province put out a petition for proposals in April 2001. In October 2001. CNSI. one of merely two houses to offer. received the contract for its $ 15 million proposal. The trade called for CNSI to finish and deploy the new processing system by the HIPAA conformity deadline. which was 12 months off. In actuality. the system debuted on January 21. 2005. about 27 months subsequently. However. the severely lost deadline was barely Maine’s biggest job. The new system failed on many degrees. Shortly after its rollout. the new system was rejecting claims much more often than the old system had. Most of the rejected claims were being held up as suspended. a appellation normally applied to claim signifiers that contained mistakes. The suspended file grew rapidly. doing 1000000s of dollars in claims to be held back. Within two months. 300. 000 claims were frozen.

The Bureau of Medical Services could maintain up neither with the figure of phone calls nor the processing of the suspended claims. The 65 members of the DHS/CNSI squad worked feverishly to repair package bugs. but their attempts were accompanied by a deficiency of respect for critical direction guidelines. Meanwhile. some suppliers who weren’t acquiring paid were forced to turn away Medicaid patients or even close down their operations. Others sought bank loans to maintain their patterns fluid. Even the state’s fundss were threatened due to the important part of the province budget that Medicaid on a regular basis ate up. Charlene Kinnelly. executive manager of Uplift Inc. . a non-profit-making service supplier for the mentally disabled and mentally ill. reported that the province owed her organisation $ 250. 000. Seven thousand other not-for-profits and healthcare service suppliers had non been compensated decently. Maine began publishing interim payments to suppliers that were based on their mean claims. The claims system package was error-prone. even publishing cheques to physicians for their entire charges for a process alternatively of the sums that were really covered by Medicaid.

Overpayments finally recovered by Maine Medicaid totaled $ 9 million. Suppliers were holding trouble make fulling out the new claim signifiers right. which was non a large surprise since some of the signifiers required 30 to 40 Fieldss of information. The wrong signifiers were among those claims that were flagged for the suspended file. CNSI recommended that all suppliers re-enroll so that their information would be complete harmonizing to the new system’s demands. The section chose. alternatively. to reassign bing information from the old system. which was considered uncomplete by the new system. Adding to the pandemonium when the jobs began was the fact that merely 13 people were on staff to manage client service calls from 7. 000 suppliers. The catastrophe cost the province an extra $ 30 million. More than a twelvemonth after turn overing out the new system. Maine was the lone province that still had non satisfied the HIPAA demands. CNSI had ne’er earlier designed a Medicaid claims system. Furthermore. that the province received merely two proposals. and the one from a house named Keane inquiring twice every bit much money as CNSI’s. should hold been a cause for dismay. J. Davidson Frame. dean of the University of Management and Technology in Arlington. Virgina. described the weak response to the Request for Proposal ( RFP ) as a mark that its demands were unreasonable.

Had Maine’s procurance section sensed this at the clip. the RFP could hold been revised and the province probably would hold received more commands that were in line with Keane’s $ 30 million initial proposal. After all. Keane had worked on similar systems. including Maine’s Medicaid eligibility processing. B. Chatterjee. president of CNSI. admitted that his company lacked the experience of working with Medicaid systems and described CNSI as “a no-name company” looking for an entry-way into claims treating system direction. Chatterjee assumed that his Rockville. Maryland–based information engineering house could trust on terminal users’ Medicaid background to organize a successful squad. Mentioning the scalability demands of the undertaking. CNSI planned the scheduling based on J2EE ( Java Platform Enterprise Edition ) . which was a mismatch with the bequest codification from the old system.

Dick Thompson. who was so caput of procurance for the province of Maine. defended the determination to choose CNSI by indicating out that the province was non in a place to overspend and the clip restraints of the HIPAA deadline gave the province small clip to detain its determination. Budget concerns besides prevented the undertaking from being properly staffed. which slowed development during the design stage and hampered response clip once the ailments started stacking up.

The squad had trouble acquiring confer withing clip with the Medicaid experts on staff at the Bureau of Medical Services. The DHS IT staff members and CNSI contractors were forced to do judgements about Medicaid regulations and demands without the proper input. The squad so had to reprogram parts of the system once the Medicaid experts became available. One interruption came when the federal organic structure that runs Medicaid extended the HIPAA deadline by a full twelvemonth to October 1. 2003. However. the DHS squad continued to contend against the tide. fixing mistakes. composing new codification to suit Medicaid regulations alterations. and adding storage capacity and treating power to back up the new regulations. Feeling that they would ne’er catch up. the squad began to take cutoffs. Comprehensive testing of the system was deemed impossible due to clip restraints. Furthermore. despite informing suppliers of the new system and new supplier ID codifications. the province did non offer developing for suppliers on the new system ; nor did the province decently train the staff that would be responsible for fielding calls from suppliers with jobs.

When the DHS. now merged with the Department of Behavioral and Developmental Services as the Department of Health and Human Services ( HHS ) . decided to establish the new claims treating system in January 2005. it did so with a clean interruption from the bequest system. There was no backup or parallel system to back up the deployment because the bequest system was incompatible with the new codification Numberss ( stand foring supplier revenue enhancement ID Numberss and patient societal security Numberss ) and electronic claim signifiers. and a parallel system was non executable economically or technically.

The one backup program in topographic point was a proviso to pay suppliers for two to four hebdomads based on their mean monthly claims payments in instance of a failed deployment. Within a few yearss of traveling unrecorded with the system. Craig Hitchings. manager of information engineering for DHS. noticed that the system was suspending an remarkably high figure of claims. around 50 per centum or 24. 000 claims in the really first hebdomad. The old system had rejected claims at a rate of 20 per centum on norm. And so the calls started coming in. Suppliers whose claims had been suspended were registering 2nd claims. which were suspended automatically by the system because they were tagged as extras. The Bureau of Medical Services could non rectify the bungled claims about as fast they were coming in. Soon there were 100. 000 claims stuck in the system. Doctors were having statements in the mail for rejected claims over and over. Medicaid was behind on $ 50 million worth of payments. At the same clip. Hitchings and CNSI discovered scheduling and design jobs in the system that limited the size of claim files to an unreasonable 1. 000 lines of codification.

Suppliers naming to kick were seldom able to acquire through and suffered through apparently endless waiting periods on clasp when they did. Maine’s health care system was in crisis. and the province budget was in danger of go offing. In March 2005. Maine hired XWave. a undertaking direction adviser specialising in integrating. for over $ 860. 000 to compensate the ship. The jobs persisted and as summer drew to a stopping point. the backlog of suspended claims had reached 647. 000 and suppliers were owed $ 310 million in payments. Rebecca Wyke. caput of Maine’s funding section. awarded a $ 7 million contract to the accounting house Deloitte & A ; Touche to do certain that the province would be able to pay its Medicaid duties and to assist screen out the muss of measures. Thompson. who by now had been named CIO by Wyke. brought in Jim Lopatosky. an Oracle database specializer. to make full the function of operations director.

Lopatosky and XWave both determined that the undertaking suffered from uneffective undertaking direction and a famine of communicating among Maine’s IT staff. CNSI. and the terminal users. Lopatosky worked to better communications so that workers from the two subdivisions of the squad wouldn’t work on the same parts of the system unaware of what the other was making. He besides prioritized the troubleshooting procedure so that suspended claims could be cleared before less critical work was done. Thompson added another important piece to the mystifier in October 2005 by naming Dr. Laureen Biczak to be the organization’s Medicaid expert. Thompson said. “It was something we should hold done from the start: have person who knew the concern [ of Medicaid ] working full-time on the undertaking. ” Get downing in January 2006. inquiries from suppliers were filtered to Medicaid specializers working under Biczak if they were business-process issues. or to the IT section if they were hardware or package issues. With this filtrating system in consequence. Maine was able to cut down the claim suspension rate to about 15 per centum with the staying 85 per centum of claims being processed decently as paid or denied.

However. some suppliers still wondered why so much clip and money was spent on a system that so far has non performed any better than the system it replaced. and. worse. caused injury to healthcare suppliers and their patients. Chatterjee. whose company lost about $ 10 million on the undertaking. believed that CNSI and the province dullard duty for half of the jobs. and suppliers who made errors on their claim signifiers could be blamed for the other half. He besides insisted that Maine is better positioned to travel frontward than other provinces that updated their bing systems instead than constructing state-of-the-art new systems.

In fact. CNSI has received extra province Medicaid contracts in the aftermath of its work with Maine. Maine was hopeful that its system would eventually be to the full functional sometime in 2006. Beginnings: Allan Holmes. “Maine’s Medicaid Mistakes. ” CIO Magazine. April 15. 2006 ; Victoria Wallack. “No One at the Helm: Maine Medicaid Struggles On. ” Ellsworth American. December 22. 2005 ; Susan M. Cover. “Stiffed by Software. ” Kennebec Journal. May 1. 2005 ; “Computer Debacle Could Cost Maine Medicaid Millions in Federal Matching Funds. ” World Wide Web. freerepublic. com. September 28. 2005 ; Todd Benoit. “From a Medicaid Disaster. Hope. ” Bangor Daily News. June 25. 2005 ; “Maine Providers To Receive Payments Delayed by Medicaid Computer System. World Wide Web. ihealthbeat. org. March 7. 2005 ; “Maine Addresses Medicaid Billing System Problems. ” World Wide Web. ihealthbeat. org. April 6. 2005 ; and Victoria Wallack. “Computer Snafu Could Cost State $ 4 Million. ” Boothbay Register. July 21. 2005.

CASE STUDY QUESTIONS
1. How of import are information systems for Maine’s Department of Health and Human Services? Analyze the impact of its faulty Medicaid claims processing system. 2. Measure the hazards of the Medicaid claims treating system undertaking and cardinal hazard factors. 3. Classify and depict the jobs the Maine Department of Human Services faced in implementing its new Medicaid claims processing system. What direction. organisation. and engineering factors caused these jobs? 4. Describe the stairss you would hold taken to command the hazard in the IT modernisation undertaking. 5. If you were in charge of pull offing this undertaking. what else would you hold done otherwise to increase opportunities for success?

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