Among the many profound changes spelled out in Sunday’s passage of healthcare reform is this: An estimated 16 million more low-income people nationwide will become eligible for Medicaid. The question now is, How can the current system support rising enrollment? States that have already invested in a modern web-based Medicaid Management Information System (MMIS) will have the flexibility and scalability to deal with an increased Medicaid recipient population.
But that approach won’t come easily. As is, US patients are finding it increasingly difficult to get health services under Medicaid as more doctors drop out of the program due to low reimbursement. That means one thing for you: Now more than ever, contractors can play a pivotal role in helping restore provider faith in the reimbursement process.
That’s where CNSI comes in. Ever since the Rockville, Md.-based IT company entered the Medicaid market in 2001, it has offered a fresh perspective on ways IT can be transformed for smarter healthcare delivery. Looking beyond outdated mainframes, CNSI has offered a ground-breaking approach: bringing various silos of information exchange under one system, based upon relational databases. That holistic view offers reduced healthcare costs — and fewer instances of fraud — among state customers such as Michigan, Washington, South Dakota, and Maine. Here, CNSI CEO B. Chatterjee (right) shares seven steps on restoring provider confidence in the Medicaid reimbursement process.
Strengthening Medicaid reimbursement: Seven steps
Restoring provider confidence in the Medicaid reimbursement process begins with strengthening the program’s information systems and applications. Since its entry into the market in 2001, CNSI has promoted more flexible infrastructure for Medicaid efficiency. In addition to increased recipients, next gen MMIS changes can adapt in real time to provider reimbursement rates or any legislative changes that may impact the adjudication of claims. CNSI’s own approach is based upon the following:
1.) Leverage a “rules engine” tool. System developers struggle to keep in step with evolving business dynamics. So do Medicaid offices, which face individually evolving state rules. To address the issue, CNSI developed a tool, RuleIT, which easily makes changes in an application based upon variables such as new legislative, business, and claims requirements. That translates into speed of program implementation and ultimately reduces costs to allow Medicaid to better align and improve service to its constituents.. The industry average for a Medicaid director to deploy a new business program is 10 to 12 months. RuleIT shortens that timeframe to three to four weeks.
2.) View Medicaid market from three perspectives. Specifically, the recipient (patient), provider (doctors practices, healthcare and hospital groups), and payer (insurance companies, Medicaid). “You have to look at the issue from all three angles rather than just the ‘payer’ angle, ” says Chatterjee. CNSI learned that lesson early on, with the state of Maine. “In future implementations, we started taking measures of how the other two stakeholders’ interests would be served along the way,” he says.
3.) Build in data model efficiencies applicable to all three stakeholders. While CNSI focuses on the Medicaid payer space, it has built efficiencies into its data model that can be applicable to recipients and providers as well — in additional healthcare programs. That versatility recently landed CNSI a contract with Social Security Administration through Southeast Michigan Health Information Exchange (SEMHIE). CNSI is implementing the process to exchange standards based health continuity care document related to instances where an individual files a Social Security claim. Currently, SSA has to validate the information in a manual process with a specific hospital where the procedure was done. That process can take over 400 days. CNSI’s implementation, by contrast, would cut that timeframe down to just a few weeks..
4.) Offer a feature-rich web portal, with scalability features. That’s been CNSI’s approach with each iteration of its system. The company has also provided separate self-service portals for clients and providers. Whether a mom-and-pop shop paid by Medicaid to care for a few recipients or a large hospital that submits thousands of claims every week, each one’s ability to tap into a self-service component minimizes state overhead expenses. More importantly, the feature generates efficiency for providers, their cash flow, and ability to monitor where the money is going.
5.) Standardize interfaces for interagency data exchange. Even on the state level, the Medicaid system doesn’t exist in isolation. It has to interact with several different agencies and the federal government for data exchange. Based upon that reality, CNSI implemented a services based infrastructure for data exchange, similar to a “hub and spoke” model. That model allows for central management of interfaces and minimizes the cost of implementing changes in the system.
6.) View Medicaid as a launching pad for health information exchange. Millions of Medicaid recipients spells millions of transactions. The state gets that data; it’s time to make that data available to medium and large providers, specifically in relation to meaningful use, says Chatterjee. Toward that end, CNSI has been in discussion with states about health information exchange. “We have the mechanism for sharing this data securely on the nationwide health in formation network … if standard transactions were to come in, we could service them,” he says.
7.) Keep in mind complex security challenges. “These securities are access-based securities … HIPAA mandates that anytime anybody looks at your records or my records that they have permission and you know about it,” says Chatterjee, adding: “How would these things, over a period of time, get solved?” In CNSI’s case, the company is tapping into its work with another government customer for transferable answers. CNSI is working with the FAA in identity management and logical access. Those components related to information security would be relevant in the Medicaid space. “We are making progress and bringing similar thought process and experience to this particular area — with healthcare reform now a reality, that’s needed now more than ever,” says Chatterjee.