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System breakdown
Thanks to MaineCareís computer problem, 272,000 Mainers, including our poorest children, elderly, and disabled, must consider themselves "lucky" there are any doctors willing to treat them
BY SARA DONNELLY


In August, Sandi Campbell lost the dentist her three children have gone to for eight years because the stateís system to pay him is broken. Campbell, a single mother living in Freeport, says her dentist stopped accepting MaineCare, the state Medicaid program which pays her childrenís dental and healthcare bills because he had not been paid properly for claims since January 2005.

On February 14, 2005, the Living Independence Network Corporation (LINC), an outreach program for disabled children, closed its doors for one week because the bills it submitted to MaineCare hadnít been processed for a month and a half. The staff of 50 was temporarily laid off without pay until LINC received emergency loans from the state.

In March, Portland psychologist Frank Luongo stopped seeing new MaineCare patients because he also hasnít received accurate payment from MaineCare since January. Instead, he receives approximate payments which do not relate to actual bills, making it impossible for him to balance his financial records.

"The whole MaineCare payment system has been in a state of utter chaos and disaster for almost a year now," Luongo says.

Gordon Smith, Executive Vice President of the Maine Medical Association, a physiciansí trade group with 2700 members, says most private practices in the state (including some 900 of his members) have stopped accepting new MaineCare patients because the new computer program installed at the state Department of Health and Human Services in January has slowed claims payment to a crawl.

You donít have to be some kind of government affairs or healthcare expert to understand this is a big problem. As the stateís Medicaid program, MaineCare pays the health bills of 272,533 low-income Mainers, according to August Office of MaineCare Services figures, or about one out of every five of us. Children, the elderly, and the disabled make up roughly 90 percent of MaineCare patients, according to DHHS.

The 7000 Maine physicians and other health practitioners who take MaineCare patients generally make about half the going hourly rate when they see Mainers on the program. But, despite the monetary loss, health providers have traditionally made time for MaineCare for a number of reasons ó because they canít stomach turning away the poor and sick, because their practices exist in a particularly impoverished area, or because MaineCare reimbursements, despite being thin, were always reliable income.

Lately, however, many MaineCare practitioners have had to wait weeks and months to receive payment for seeing patients. And many of those who have been paid have been cut loans, called "interim payments," which amount to a calculated average of the cost of services rendered rather than any real amount billed, since the real claim is trapped in the computer.

Smith refers to the MaineCare billing mess as the last straw.

"Theyíre lucky thereís anybody out there today seeing MaineCare patients given the nature of the problem," he says. "I canít defend it because itís indefensible."

The indefensible problem is the Maine Claims Management System (or MECMS), a computer program created for the state by a Maryland company called Client Network Services, Inc. (CNSI) to streamline submission, evaluation, and payment of the $1.5 billion MaineCare program. MaineCare is run by the Office of MaineCare Services, which is a part of the state Department of Health and Human Services.

Since it went online in January 2005, the MECMS program has, by universal agreement, been nothing but trouble. Mary Lou Dyer, the Managing Director of the Maine Association for Community Service Providers, a trade organization for 450 of the stateís practitioners working with the developmentally disabled, has a more pungent term for MECMS. She calls it "a nightmare."

MECMS rejects thousands of accurate claims. It can take months to pay claims it does approve and often pays them in bizarre, inaccurate amounts. Since January, it has overpaid 137 providers by more than $100,000 a piece. This amounts to excess payments of at least $13.7 million, which the state plans to reclaim from the providers involved by docking future MaineCare payments.

As of September 25, according to a DHHS report presented to the Joint Standing Committee on Appropriations and Financial Affairs, there are 347,181 claims, representing millions in money owed to healthcare providers, "in suspension" ó meaning they havenít been chucked out and they havenít been cashed in. Theyíre just in payment limbo.

When claims payment isnít working, MaineCare providers donít get paid. When providers go months without getting paid, books canít be balanced, mandatory auditing becomes overwhelming, and accepting MaineCare patients can stop making sense. Suddenly, the family doctor ó who knows your family medical history, has treated your child from birth to age four, and can charm your toddler into asking for a shot in the arm ó is no longer the family doctor. You and your toddler are sent packing.

And no one is assuming full responsibility for this mistake threatening thousands of Mainersí healthcare.

WHAT HAPPENED?

Pretty much everyone involved readily admits that the MECMS MaineCare program was really screwed up back in January when it was launched, even if they canít recall exactly who approved going ahead with it at the time or why a test run wasnít done while the old system was still operational.

In March, after two agonizing months of bills going unpaid, Governor John Baldacci appointed Deputy Commissioner J. Michael Hall to manage the reconstruction of the computer system. In April, Baldacci formed the MaineCare Provider Advisory Group to weigh in on the transition; provider advocates Smith and Dyer are both members.

A top-level CNSI technician, often the president of the company B. Chetterjee, has been on the ground helping to repair the system since January. The state also hired two outside consultants to help fix the problem, the Canadian software company XWave for the tech end and Deloitte Consulting of New York City to handle the management organization.

In early March, according to the Bangor Daily News, DHHS Commissioner Jack Nicholas promised MECMS would be fully operational by the end of that month, "no ands, ifs, or buts."

Several ands, ifs, and buts later, Nicholas now plans to have the program running smoothly by January 1, 2006, according to Mike Norton, spokesperson for the DHHS Commissionerís office. This will be exactly one year after it was launched without a backup plan and without extensive testing.

Strangely, CNSIís Web site features the MEMCS program as a success story at www.cns-inc.com:

"Using our base system, "eCAMS", CNSI designed a solution to overcome the challenges facing the [MaineCare] agency in the near future, including regulatory, business process, and technological changes."

 

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Issue Date: October 7 - 13, 2005
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