New York State Assembly. Early Intervention Fiscal Agent Implementation

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Allyson Stevenson
8 years ago
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1 Testimony of the New York Health Plan Association to the New York State Assembly on the subject of Early Intervention Fiscal Agent Implementation October 22, 2013

2 INTRODUCTION The New York Health Plan Association (HPA), comprised of 22 health plans that provide comprehensive health care services to nearly seven million New Yorkers, appreciates the opportunity to present its members views on Early Intervention fiscal agent implementation. Our member health plans have long partnered with the state in achieving its health care goals including improved access to quality care in its government programs as well as providing access to care that exceeds national quality benchmarks for enrollees. Our plans include those that offer a full range of health insurance and managed care products (HMO, PPO, POS, etc.), public health plans (PHSPs) and managed long term care plans. The New Yorkers who rely on these plans are enrolled through employers, as individuals, or through government sponsored programs Medicaid Managed Care, Child Health Plus, Family Health Plus and Healthy New York. Accordingly, we appreciate the opportunity to offer our view on the implementation of the Early Intervention program s fiscal agent. HPA and its member plans are working diligently with the Department of Financial Services (DFS), the Department of Health (DOH), and the state s fiscal agent to resolve the issues related to the implementation of the Early Intervention (EI) program s fiscal agent. The core problem is that the new EI framework relies on an information technology (IT) claim submission, payment and remittance approach that conflicts with traditional managed care IT provider claims processing. Contributing to the IT systems issue has been difficulty on the part of plans to identify claims as EI claims submitted by the state fiscal agent. Background On April 1, 2013, McGuinness Associates (McGuinness) became the interim state fiscal agent. This new state fiscal agent supplanted the prior EI system operated by the municipalities. EI billing that had 2 P a g e

Our member health plans have long partnered with the state in achieving its health care goals including improved access to quality care in its government programs as well as providing access to care

3 once been the domain of the various municipalities now became the responsibility of one statewide fiscal agent. Under the municipal EI claims/payment system both the plan payment and the remittance went to the municipality. Municipalities paid providers and then worked with plans to reconcile third party payments. Unfortunately due to time constraints, implementation of the new EI system prevented needed dialogue to occur between the State, its fiscal agent and health plans. The new system required that the provider submit the claim to the fiscal agent, the fiscal agent submit the claim to the health insurance carrier, and the health plan to either pay or deny the claim to the provider, and send a separate remittance to the state fiscal agent for further processing and provider payment. Virtually all plan IT systems send both the payment and the remittance to one entity, traditionally the provider. The splitting of the payment and remittance under the state fiscal agent model did not reflect health plan payment processes and required plans to adjudicate EI claims using a manual process. On October 1, 2013 Public Consulting Group (PCG) took over as the state fiscal agent. While PCG was now officially the state fiscal agent they contracted with McGuinness, the interim fiscal agent, to continue in its role of claims processing. PCG has not made any changes to how EI claims are processed. Identification of Early Intervention Claims Claims submitted by the fiscal agent are not being identified by plan IT systems as EI claims, but rather normal provider service claims for physical therapy, occupational therapy, or speech therapy. The inability of plans to determine if the claim is an EI claim has resulted in confusion and delay in claim processing. 3 P a g e

Municipalities paid providers and then worked with plans to reconcile third party payments.

4 For example claims that were submitted to plans did not contain an express field/location identifying that the claim was submitted by the state fiscal agent as an EI claim. In most cases the existing fields used for identification of the billing party were populated with the provider s claim information. The only way plans could determine that the claim was an EI claim was in supporting documentation. That required plans to forego their automated claim processing system and instead process these claims manually. A workable solution to this issue was for the fiscal agent to add a unique TL modifier which would permit plan IT systems to recognize EI claims. Unfortunately the identification of EI claims continues to be an issue. Many of the claims submitted by McGuinness are identifiable using specific identifier fields, but when McGuinness sends them to their claims processing clearinghouse, Emdeon, the specific fields are overwritten with Emdeon s information. This makes the claim difficult to identify as an EI claim submitted by McGuinness, as Emdeon submits claims for all types of providers. Conclusion and Recommendations As HPA continues to work with DOH and DFS to resolve the backlog of EI claims from April 1 st there are areas in which the EI state fiscal agent framework can be modified to eliminate these ongoing issues moving forward. First, there must be a clear identifier on the claim that identifies the claim as an EI claim submitted by the state fiscal agent. This is essential in ensuring that the EI claim is adjudicated properly and in a timely manner. Without a unique identifier or taxonomy code plans will continue to struggle with identifying EI claims and the payment process will be delayed as a result. 4 P a g e

The only way plans could determine that the claim was an EI claim was in supporting documentation.

5 Secondly, the EI fiscal agent must become the center and focal point of EI claiming and payment. Providers should bill the fiscal agent and be paid by the fiscal agent. The fiscal agent should bill the plan and receive both the plan payment and remittance like the earlier municipal model. This would ensure providers are paid in a timely fashion and in a correct amount. The fiscal agent would be recognized by the plans as the EI billing agent and any related issues on payment reconciliation could be handled between the plan and the fiscal agent. This would also provide the state with better information about EI claim processing by third party payors. Once again, we thank you for the opportunity to share our views today. HPA and its member plans remain committed to working with you and your colleagues on implementation of Early Intervention program fiscal agent. 5 P a g e

This would ensure providers are paid in a timely fashion and in a correct amount.

Early Intervention Service Coordination Public and Private Insurance Use Determination

Early Intervention Service Coordination Public and Private Insurance Use Determination POLICY 1. Families whose children are enrolled under private insurance plans are required to use their child s benefits