EDITORIALS

Taking care of MaineCare

Diagram showing the Maine Department of Health and Human Services' claims management processing system.
Image courtesy of DHHS
Diagram showing the Maine Department of Health and Human Services' claims management processing system.
Posted May 07, 2012, at 2:34 p.m.
Diagram showing the Maine Department of Health and Human Services' claims management processing system.
Image courtesy of DHHS
Diagram showing the Maine Department of Health and Human Services' claims management processing system.

If you’re on MaineCare or you’re a doctor or medical care provider, the computer problems at the Maine Department of Health and Human Services concern you because you rely in some way on the department’s ability to accurately process medical claims.

If you live in Maine, you probably care about errors because a lot of state and federal tax dollars are used to fund the department. In 2011, the total budget was $3.3 billion.

So you might have been disconcerted to learn recently that the department had overpaid $10.7 million to providers for about 7,700 Mainers who no longer were eligible for MaineCare, which is Maine’s version of Medicaid.

It happened because a system responsible for determining whether a patient was eligible for services was not communicating with a different system responsible for processing the claims. That means people who were deemed ineligible did not have their cases closed when they should have been.

It’s an unfortunate mistake. But it’s not a calamity when you look at the greater context. If anything, the department’s biggest hurdle will be to overcome its chronic image problem. Though the current situation is different, the department has experienced serious data-management problems going back nearly a decade.

Public confidence will be restored only if the department handles the problem openly, allows an independent and complete review of what went wrong, makes the best possible effort to fix the problem and then doesn’t let it happen again.

It appears the department is taking the right approach in this. After adjusting to two new claims systems in the last eight years, it doesn’t need a new one that would require employees to learn new skills and likely necessitate a fresh round of troubleshooting. And having another state take over claims processing, as has been suggested, could prove costly.

Instead, the department is working to improve its Maine Integrated Health Management System, launched in 2010. The department has a team of people from its office, the Office of Information Technology, Office of the State Controller and Office of MaineCare Services that is analyzing how exact improvements can be made, DHHS communications director John Martins said.

In addition, the Office of Program Evaluation and Government Accountability is conducting a review. And people experiencing problems with the system can write in directly online to let MaineCare know.

“There clearly are issues with the system that need to be addressed, and we are working to better understand the relationship with all data systems, including a decade-old eligibility system and how it interfaces with the new claims management system. This is — and will continue to be — a work in progress,” Martins said.

Fixing the problem is not as simple as training employees, but it does involve them, as computer programs will do what they are told to do. The people at the department are working to develop a mechanism to double-check information feeding between system components.

And they’re making progress on tackling requests for system adjustments. So far they have addressed 3,200 requests since the system launched, and they have 500 more to go.

The situation is embarrassing and the department should have been more aware of the possible problems, given its history. A bright spot is that department leaders seem to grasp that this is not just about money but the trustworthiness of the state, and they already have shown they’re willing to work hard to make the complicated system better. That is a sign that improvement is possible.

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