Thursday, February 5, 2009

Medicaid's New Computer System

AJ's Dad brought this articla to my attention this morning. It seems that the new computer system implemented by AJ's state insurance (Medicaid/T19) is causing major problems for everyone. As parents of a child who has cerebral palsy, these two stories made us extremely angry. Why don't they flippin' understand these kids NEED these services and equipment?! We've had our share of fighting for therapy services for AJ, fighting for his SMO's, and obviously now for his first CI. I've pasted the article below...to read the article on JSOnline, click HERE.

New Computer System at Medicaid Agency creates backlog of cases

Ann Siverling sits nervously at mealtimes watching her 11-year-old daughter, Amanda, eat.

Amanda has cerebral palsy and sometimes has difficulty swallowing. She'll gag or choke on her food. It takes about an hour to eat one meal.

In September, a doctor recommended that Amanda receive oral feeding therapy to help her gain better control of swallowing and chewing. But she has yet to receive a single session.

For the past five months, Amanda's Medicaid payments have been delayed because of problems at the Wisconsin Department of Health Services.

Officials within the state agency acknowledge they've had trouble with a new $64.2 million computer system that handles Medicaid services. Glitches with the automated system caused a backlog of claims, preventing the state from processing some prior authorizations for therapies and medical equipment.

The agency has been unable to process about 10% of its claims for prior authorization within the 20-day time period required under state law. Some requests have taken four times longer to be approved.

As a result, about 2,500 people who use Medicaid have been left wondering when, or if, they'll get approval for things such as physical therapy, a new wheelchair or leg braces to help them walk.

The technological tangle affects only a small percentage of the 925,000 people who receive Medicaid services in Wisconsin, said Jason Helgerson, the agency's Medicaid director. And the state insists the backlog is almost resolved: By Monday, the remaining 793 of about 4,100 backlogged claims will be cleared out, officials say. The agency replaced its 30-year-old Medicaid computer system in November.

"Any conversion of this size and scale is going to have implementation issues," Helgerson said.

Health care providers interviewed by Public Investigator said the approvals ground to nearly a halt in late October and have just started trickling in during the past week or two. Some providers have administered care while hoping that the state will approve payment.

But other patients have had to wait months.

As each week passed, Siverling grew increasingly frustrated with her daughter's lack of care.

Then in January, Amanda's therapist received a letter from the Department of Health Services that said Amanda had been approved for 16 weeks of therapy. The deadline to complete the services? Dec. 31, 2008 - a few weeks before the letter was even sent.

In the meantime, Siverling remains especially vigilant at meal times.

"We've had a lot of scary times," she said. "We pound on her back to clear her out a little bit."

The agency said it is now looking into Amanda's case.

Computers have control
The new Medicaid computer system handles nearly all aspects of the program.

The big glitches affected Medicaid's prior authorizations, where the state must approve payment before therapy is given or a wheelchair is fixed.

With the old system, workers passed a paper file from desk to desk with all the proper documentation.

The new system is automated and mostly paperless, Helgerson said. At first, it didn't work properly, and that's how claims got backed up.

Health care providers who submitted the information also were unfamiliar with the system and had problems that added to the backlog, Helgerson said.

The agency offered an emergency approval process for high-priority cases, such as a suicidal patient who needs therapy or a person needing nursing care in their home.

Patients hit the hardest were those waiting for durable medical equipment, including leg braces or devices to help with bathing.

Jackie Petite, a rehab coordinator with Knueppel HealthCare Services, said her medical equipment company has about 100 claims that have not been processed within the 20-day time limit.

Patients, and quite often parents of young patients, have grown increasingly frustrated with the holdup.

"Everything just kind of stood still," Petite said. "Our hands were tied."

The state says authorization for medical equipment takes longer than other requests because it is an area closely watched for fraud.

While some health care providers and the state seem confident the bugs in the new system will be worked out, some people relying on services are worried about the effects of the delay.

Cheryle Ciardo has a 3-year-old granddaughter, Jaylynn, who has been waiting for leg braces for nearly five months. Jaylynn has cerebral palsy and uses leg braces to keep her feet in the correct position.

Without the braces, Jaylynn has had trouble standing, her grandma said.

"As she gets older, her equipment is going to mean more to her," Ciardo said. "It means so much because these children and adults, they need their equipment to make their lives better."

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