MEDICAID PROGRESS

A newly released federal report says Maine is making substantial progress in fixing its failed Medicaid computer system, a failure that stranded hundreds of health care professionals through much of this year without payments adequate to keep their doors open. The report, by the Centers for Medicare and Medicaid Services, also warns of high-level risks to the stability of the Maine system unless more protections are put in place.

The good news is that federal report recognizes Maine is properly repairing both computer and management failure since its computer meltdown last winter. At the time, the new computer system went online to pay Medicaid claims filed with the state. The old system, because of coding changes and other reasons, was permanently unplugged just before the new system imploded. Since then, a painstaking, highly public appraisal of the problem has both exposed flaws at the Department of Health and Human Services and provided hope that the department was serious about correcting them.

The Centers for Medicare and Medi-caid Services (CMS) was persuaded by the progress to remain willing to fund its share of the upgrade, which Maine estimates will require another $10 million. It does this based on improvements that have allowed the system’s core claims processing to adjudicate most claims while Maine Claims Management Systems staff has reduced a huge backlog of claims. The federal officials also reported they were impressed by the management team the Baldacci administration put in place after the crisis.

However, three related risks, all rated high by CMS, could affect the outcome of this project and the state’s ability to comply with other large-scale technology changes. They are a risk that project management plans are inadequate to allow the repairs to be made on time. Second, that Maine does not have the ability to test these types of conversions – though the report noted Maine was working rapidly to correct this. Third, that system changes are put into effect without the code being properly tested, risking a major defect in the final product.

The CMS team identified a dozen high- and medium-level risks altogether. A DHHS official says the department is working on these issues and will continue to report to CMS. Based on earlier progress, this is encouraging.

In the time since the CMS inspectors were in Maine, in mid-July, DHHS says claims management has improved its processing from 60 percent to about 80 percent of claims. That, considering the number of suspended claims that will always be in a system, is tangible progress. Further changes outlined by federal inspectors should encourage the state to keep going that way.