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NC legislators ready to dissect Medicaid billing

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When NCTracks first rolled out, some medical providers couldn't log in. When NCTracks first rolled out, some medical providers couldn't log in.
RALEIGH, N.C. -

Hospitals and doctors' offices across North Carolina are still struggling to work with a new Medicaid billing system three months after it was switched on, even as state officials proclaim the network the job for which it was created is largely getting done.

Medicaid officials tried to lower expectations before flipping the switch July 1 on the "NCTracks" billing system that replaced one built in the late 1970s. The state Department of Health and Human Services says it has worked out many of the kinks on its end, processing almost 50 million claims and $2.6 billion in reimbursement checks. Yet providers say they still face problems getting paid.

When the system first rolled out, some medical providers couldn't log in. Then claims that traditionally were approved were denied. Sometimes people waited an hour on hold to speak to a representative of the company that the state agreed to pay $484 million over a decade to build and operate the system, then they didn't get questions answered.

"They have taken a very straight-forward process and complicated it to the 'Nth' degree," said Kim Sparks, the administrator at Nash OB-GYN Associates in Rocky Mount, who attended training sessions before the system rollout. She said they didn't help — her practice had more than $300,000 in Medicaid claims unpaid by the state at one point. Less than half those complaints have been resolved. The practice needed a bank loan to cover payroll.

Nothing like NCTracks "has crippled this practice so severely financially," Sparks said.

Things are slowly getting better, according to the Department of Health and Human Services and vendor Computer Sciences Corp. Call center wait times are meeting goals, claim approval rates are near or exceeding targets and providers are learning new service coding that tripped up many.

CSC said in a release that a "small percentage" of providers still have issues. But Joe Cooper, chief information officer at DHHS, acknowledged the dissatisfaction among the medical community. There are 70,000 providers statewide.

"We're not going to stop until every provider is happy with what they're doing and how to use the system," he said in a recent interview. Still, he added, "we absolutely anticipated this would be a difficult transition for a lot of our providers."

Such words aren't enough for legislative leaders who have summoned him, DHHS Secretary Dr. Aldona Wos and CSC for a General Assembly oversight meeting this coming week expected to last several hours. They want to know why so many of their constituents aren't getting paid. Medical providers also will speak.

Democrats and Republicans have shown rare unity about NCTracks after a divisive General Assembly session. Senate leader Phil Berger, R-Rockingham, promised to Minority Leader Martin Nesbitt, D-Buncombe, last month the parties would work together on addressing NCTracks problems.

Still, the recent NCTracks complaints have fed a narrative by Democrats and other critics of Republican Gov. Pat McCrory's administration that Wos and her lieutenants are ineffective.

"They're accepting absolutely no blame or responsibility for what's going on," Nesbitt said. While DHHS is fixing problems of scores of constituents, in some cases advancing them money, "we can't run state government based on complaints."

NCTracks has been marked by cost overruns, a stinging audit and a canceled contract with another provider before CSC took it over in 2008. Republicans point out delays and problems occurred before McCrory took office in January.

The future of NCTracks is critical as Medicaid serves more than 1.5 million North Carolina residents. Medicaid is taking up ever-increasing costs within the state budget, forcing Republican lawmakers to add another $1.1 billion in spending toward the program over the next two years.

The prevailing problem involves identification numbers assigned to each provider for billing the state. Under the old system, each provider got one ID number. Today, each provider has new codes based on services, meaning a practice with several locations gets a distinct number for each office. That prevents providers from billing for services they don't offer, which helps curb fraud.

DHHS suggests many medical providers were either unaware of those changes — Cooper said less than 15 percent of them have participated in training — or they are using codes they don't qualify to use, leading to denied claims. But the North Carolina Hospital Association blames some problems on the system not recognizing codes used nationwide.

Dr. Adel Mohamed and his urology practice partner in Smithfield are waiting on $62,000 in Medicaid claims. He said no one ever told him about the code changes until the system went live. The doctors haven't taken a salary in two months to help with cash flow.

"We've had so many obstacles and errors," Mohamed said. The state has paid $65 million in advance to 144 approved providers while their problems are getting worked out, DHHS said.

Some medical providers are being forced to choose between risking the future of their clinics and limiting the number of Medicaid patients they serve, said North Carolina Medical Society CEO Bob Seligson. Nearly 300 physician practices have contacted the society since July 1 with NCTracks complaints.

DHHS provided data showing the mixed results to date on meeting goals on handling claims. For the week ending Sept. 20, less than 57 percent of the hospital claims received were approved, compared with a target of 68 percent. For retail pharmacists, the approval rate was 73 percent, compared with a 50 percent target.

Cooper blamed CSC for failing to staff the call center fully early on, exacerbating the problems. CSC had to pay $56,000 in penalties for failing to meet contract standards, DHHS said. CSC said the company was hampered by high employee attrition and training requirements but expanded staff and call center times.

Now the center receives about 4,000 calls daily and last week picked up more than 90 percent of calls within 60 seconds — a contract requirement with the state — for at least seven days in a row.

Cooper said he looked forward to the oversight committee: "I think we've got a good story to tell, and I think our trajectory for the next few months here looks very good."

Sen. Jeff Tarte, an information technology expert who's built similar health care computer billing systems, is pleased to see the system doing largely what it was built to do. But without massive training efforts for providers, delays will continue, he said.

"It's going to be a big uphill effort, and it's going to be ugly for a while," said Tarte, R-Mecklenburg.

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