OPEGA RAPID RESPONSE REVIEW FINAL REPORT Review of MECMS Stabilization Reporting Reporting Provides Realistic Picture; Effective Oversight Requires More Focus on Challenges and Risks December a final report by 2005 the Office of Program Evaluation & Government Accountability
About the Review About the Review OPEGA Final Report: MECMS Stabilization Reporting Slide 2
Purpose ――――――――――――――――― OPEGA Sought to Answer the Question… Is the legislature being provided an accurate and complete picture of MECMS Stabilization status and the associated challenges and risks? To Answer This Question, OPEGA is focused on… � Data presented in status reports � Additional information for monitoring progress � Significant challenges impacting timely resolution � Significant risks and ramifications OPEGA Final Report: MECMS Stabilization Reporting Slide 3
Methods ――――――――――――――――― � Interviewed State officials & consultants � Reviewed relevant documents � Obtained perspectives of legislators � Observed presentations to Committees � Verified reported data and trends � Learned about key activities and processes � Interviewed sample of providers � Reviewed information on State’s website � Observed progress made over time OPEGA Final Report: MECMS Stabilization Reporting Slide 4
Overview of Overview of MECMS Situation MECMS Situation OPEGA Final Report: MECMS Stabilization Reporting Slide 5
MECMS History • MECMS Phase I went live on January 27, 2005 • MECMS replaced 25 year old Maine Medicaid Information System • New system required by CMS to meet HIPAA regs; funding project at 90% • MECMS project began in 2001 when DHS hired CNSI • In 2001, info systems for DHS were the responsibility of the Division of Technology Services within DHS • The IT function for DHHS was absorbed into the Office of Technology under the State CIO earlier this year OPEGA Final Report: MECMS Stabilization Reporting Slide 6
MECMS Design MECMS is rule-based; relational database design Invoice Provider info Tables Provider Name Provider Na me Provider I Prov ider ID • Provider Provider Na Name me Service Informa Ser ice Informatio ion • Provider I • P ID Note: This is NOT meant • D • Diagnosis C Code • Provider rovider Type Type to be a picture of • S • Service C Code • Licen icense Number se Number • Charges • C MECMS Billing Rate Tables Compliance info Tables • Pro Provider ider Type Type • License Number icense Number • S • Service C Code • Effective Da ffective Date te • Billing Ra illing Rate te • Renewal Date enewal Date Invoice payment Decision/Status OPEGA Final Report: MECMS Stabilization Reporting Slide 7
MECMS Stabilization Efforts • MECMS implementation proved premature • Unable to process claims in timely manner • Stabilization efforts began immediately Stabilization efforts = Activities to resolve problems with MECMS so that claims are fully processed on regular and timely basis. OPEGA Final Report: MECMS Stabilization Reporting Slide 8
MECMS Stabilization Efforts Initial response to MECMS failures limited by weaknesses in key areas: � detailed understanding of MECMS and federal requirements including HIPAA � project management � data reliability � risk management � protocols for system changes OPEGA Final Report: MECMS Stabilization Reporting Slide 9
MECMS Stabilization Efforts MECMS Project Organization State Chief Information Officer Commissioner Commissioner OIT DAFS DHHS MECMS Project Owner Executive Steering Committee New Project Co-chairs Chief Information Officer - OIT State Controller Organization Acting Director Acting Director - OMS Office of the OMS Controller Members began DHHS Managers DAFS Managers taking shape Consultants OMS Staff in April 2005 Integrated Project Management Team Leads Deloitte OMS Medical Director - OMS Consulting DHHS Agency Information Technology Director - OIT XWave CNSI Project Director Project Manager XWave Project CNSI Managers (3) Team OPEGA Final Report: MECMS Stabilization Reporting Slide 10
MECMS Stabilization Efforts • Top administration officials heavily involved • Competent consultants filling key roles • Stronger project teams taking control • Monitoring of key performance indicators • Defined processes for setting priorities • Established protocols for making system changes • Progress tracked against detailed plans & milestones • Provider input solicited and incorporated OPEGA Final Report: MECMS Stabilization Reporting Slide 11
MECMS Stabilization Efforts • Stabilization efforts involve resolving large number of technical and data compatibility issues while adapting to changing policies • Significant strides made since July; slow but steady progress continues • Fresh claims adjudicating at rate of 85%; up from 61% in mid-June • Fresh claims suspending at rate of 15%; down from 39% in mid-June OPEGA Final Report: MECMS Stabilization Reporting Slide 12
CMS Review • CMS must ultimately “certify” MECMS • CMS measures project success as: – Stabilization of current system – Transition of operations to State staff – Completion of remaining functionality • CMS reviewed MECMS in late to July – approved continued funding at 90% – Impressed with newly established project management – Identified risks that needed to be addressed • CMS continues to monitor; Management reports progress regularly OPEGA Final Report: MECMS Stabilization Reporting Slide 13
Unprocessed Claims Needed for fully processed claim Places claims can get held up OPEGA Final Report: MECMS Stabilization Reporting Slide 14
Unprocessed Claims Claims needing special attention have exceeded capacity to resolve in timely manner Backlogged Claims - Adjudicated but not Released – rejected by MECMS cleared for payment by MECMS before processing but not paid by MFASIS due to: Timing (1 week lag) Suspended Claims – Rejected by MECMS encountered errors when Permissions Matrix (fund processing in MECMS allocation failure) claims engine Rejected in interfaces between MECMS and Remittance Advice Missing – Oracle Financials or Oracle MECMS did not generate Financials and MFASIS remittance advice OPEGA Final Report: MECMS Stabilization Reporting Slide 15
Unprocessed Claims • Majority are Suspended Claims • Difficult to resolve; many possible reasons for suspension • 43% more than 90 days old at Nov. 1st • Fresh suspensions exceed OMS ability to resolve manually; tech solutions helping keep pace • Suspended Claim inventory is dropping – 365,113 at Nov. 1 st to 321,002 as of Nov. 27 th • Root cause analysis recently completed to help identify and resolve key reasons for suspension OPEGA Final Report: MECMS Stabilization Reporting Slide 16
Interim Payments How Interim Payments Are Calculated Each Week for Each Provider Continuing Calculate Ave Weekly Pmt = average weekly unprocessed payment for Provider during Nov & Dec 2004 claims Find Total Actual = total $ actually Calculate Total Expected = (Ave Weekly Pmt) paid to Provider since implementation means x (# weeks since MECMS implementation) (both Interim and Claims payments) extended Calculate “The Gap” = reliance on Total Expected MINUS Total Actual Interim For Providers: For Providers: Payments MR, MH, NF, ICF-MR, PNMI, AFCH, All Others FQHC, RHC, TCM, Assisted Living IF IF “The Gap” > $1000 and “The Gap” > $1000 and “The Gap” > Ave Weekly Pmt “The Gap” > 30% x Total Expected THEN THEN Provider eligible for interim payment Provider eligible for interim payment of 1 Ave Weekly Pmt of 1 Ave Weekly Pmt OPEGA Final Report: MECMS Stabilization Reporting Slide 17
Interim Payments Interim Payments not tied to specific claims Plus Timing of payments unpredictable Equals Cash flow and accounting concerns for State and providers Requires Three-way reconciliation and recovery effort; pilot effort has begun OPEGA Final Report: MECMS Stabilization Reporting Slide 18
MECMS Phase II Delayed by Phase I • HIPAA Compliance problems; MECMS still missing critical functionality • Cross Over Claims • Online Claims Submission/Portal Access • Remaining Subsystems – Rate Setting (Partially Implemented in Phase I) – Drug Rebate – Third Party Liability – Maine Medicaid Decision Support (Reporting) – Surveillance and Utilization Review • Various interfaces to external entities OPEGA Final Report: MECMS Stabilization Reporting Slide 19
Challenging Environment Stabilization goal = – MECMS operating as “predictable and reliable” system with – manageable level of Suspended Claims allowing – elimination of Interim Payments Stabilization and related efforts expected to continue well into 2006 OPEGA Final Report: MECMS Stabilization Reporting Slide 20
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