THE MISSISSIPPI LEGISLATURE

Overview

PEER conducted this review primarily in response to complaints from health care providers regarding the Division of Medicaid's alleged untimely and inaccurate processing of claims submitted by health care providers.

The primary factors causing or contributing to the problem of untimely and inaccurate processing of Medicaid claims are complex and are the shared responsibility of the federal government, Medicare contractors, providers, the Division of Medicaid (DOM), and EDS (Mississippi's fiscal agent). Three issues are especially significant as the source of provider complaints:

• failure to cross claims over from the Medicare program to the Medicaid program for payment to providers;
• DOM's recouping of claims payments for previously paid claims; and,
• delays in claims payments and adjustments.

All three areas affect doctors, hospitals, clinics, durable medical equipment suppliers, and others who receive Medicaid reimbursements. Below are the primary questions PEER sought to answer relative to these issues and summary answers.

What problems has the Division of Medicaid experienced in processing health care claims of Medicaid participants whose claims are also eligible to be paid by the federal Medicare program--i.e., Medicare "cross-over" claims? Has the division attempted to resolve such processing difficulties in a timely manner?

EDS, the DOM's fiscal agent, has experienced difficulties in processing health care claims of Medicaid participants whose claims are also eligible to be paid by the federal Medicare program--i.e., Medicare "cross-over" claims. Because of these difficulties, EDS has not paid several cross-over claims or required providers to file manually to receive reimbursement for those claims, a more expensive procedure. The failure to pay cross-over claims accurately and in a timely manner occurred because (stated in order of significance as a cause):

• Although the federal government requires Medicare to cross claims to Medicaid, the federal government failed to develop coordinated federal programs and does not require adequate communication between Medicare and Medicaid fiscal agents;
• EDS failed to investigate its cross-over error reports effectively and to identify providers;
• Providers failed to provide Medicare data to EDS, as required by the Medicaid program agreement, to identify the providers;
• Metra Health failed to process Medicaid eligibility information, which restricted its ability to pass valid claims to EDS; and,
• Blue Cross Blue Shield of Mississippi failed to communicate claims transmission problems to EDS; thus, EDS never received some claims

Even though DOM and EDS were not the primary causes for most of the problems with the crossover claims, these two entities should implement corrective actions. To date, neither EDS nor DOM has been effective in addressing many of the problems related to cross-over claims.

What legal authority does the Division of Medicaid have to demand repayment of funds allegedly paid in error by the division to certain health care providers?

In July 1996, EDS, at the direction of DOM, recovered $892,618.31 in claims incorrectly paid to providers since 1994. In some cases providers paid substantial amounts (e.g., the University Medical Center repaid over $400,000). Providers had to repay the state for claims not correctly filed with EDS for services rendered to Medicaid recipients.

State law provides DOM the authority to recover any and all claims payments incorrectly paid. The Medicare cross-over claims, whose repayment DOM demanded, violated payment time limits established by federal and state law. Thus, DOM correctly enforced its authority.

Has the Division of Medicaid's fiscal agent, EDS, processed claims in a timely manner?

EDS failed to comply strictly with claims processing performance standards; however, its performance was only marginally below one standard and met the remaining standard. Claims held over thirty days for additional information to enable processing by EDS accounted for approximately one-half of one percent of the total claims received by EDS, an immaterial amount.

Recommendations

1. The Division of Medicaid and its fiscal agent, EDS, should agressively seek to negotiate agreements with Medicare contractors that will improve information transfers necessary to process Medicaid claims. DOM should request HCFA to participate in these negotiations and to insert specific requirements for information transfer procedures into future contracts with Medicare contractors. These procedures should include a requirement that contractors contact EDS immediately upon encountering problems with information transfer. The DOM also should require its fiscal agents to investigate information transfer problems as they occur and to provide documentation of such investigations to DOM.

2. EDS should follow its own procedures for reviewing and identifying providers listed on its Medicare crossover error reports. EDS should not hesitate to contact Medicare contractors to gain information needed to identify the claims received from the Medicare contractors. If the Medicare contractor is not cooperative, EDS should contact the Medicare contractor's executive-level personnel with the assistance of DOM and/or HCFA to gain the cooperation and information needed to process the Medicaid claims.

3. EDS should notify providers if the Medicare identification number is not supplied to DOM when the provider signs up for the Medicaid program. For six months after that provider enrolls in the Medicaid program without a Medicare identification number, EDS should maintain the provider on a list and make frequent contacts to inquire whether a Medicare number has been obtained. No Medicare claims should be paid by EDS, either electronic crossover or manually filed, unless EDS has accurate Medicare identification information on the provider. If the provider's Medicare identification numbers are not listed on EDS's computer system, EDS should recognize this as a problem and correct the problem prior to paying the claim.

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