ICE FOX

By Matthew Drew, Sopanha Hour, Eduardo Jimenez, Edward Martel, Paul

Munoz

Innovation and Inspiration that Ices the Information Competition

Information Systems maintained information on patients and providers

Information Systems were necessary to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA was enacted to standardize the management of patient health and records, and most notably, the protection of patient privacy

Maine’s IT staff determined a completely new system would be most cost efficient to implement.

How important are information systems for Maine’s Department of Health and Human Services?

Very tight timeline: Timeline of October 1, 2002 made the time

for vendor selection limited. Amount of time to meet the requirements

given by HIPPA

Project Size: Large project. Amount of money to be budgeted towards

it. Number of patients, doctors, hospitals,

clinics and nursing homes affected.  

Project Structure: There was not a clear structure given as

how to meet the new HIPPA requirements. The goal was out there, but the means, plan

and structure for attaining this goal was vague.

Risks of the Medicaid claims processing system project and the Key Risk Factors

Technology: CNSI had never before

designed a Medicaid claims system, and they lacked experience working with the systems.

CNSI used J2EE, which mismatched the old system legacy code.

  Maine’s requirement

proposal was unreasonable.

The staff and contractors made improper judgments about Medicaid rules.  

Risks of the Medicaid claims processing system project and the Key Risk Factors

The system suspended an usually high number of claims, and also overpaid healthcare providers for their services.

Maine did not have the staff to handle customer service with the unusually high number of claims being suspended.

Doctors were forced to either take out loans or turn away Medicaid patients

The Faulty Medicaid Claims Processing System cost as much, if not more, to fix rather than to build correctly in the first place

Impact of the Faulty Medicaid Claims Processing Systems.

Classify and describe the problems that Maine Department of Human Services faced in implementing its new Medicaid claims

processing system Baldly missed deadline to

comply with HIPPA requirements

Claims were rejected much more frequently

The suspended files grew quickly, causing millions of dollars in claims to be held back

300,000 claims were frozen within 2 months

Providers were not getting paid, as a result, turned away Medicaid patients or shut down their operations.

Classify and describe the problems that Maine Department of Human Services faced in implementing its new Medicaid claims

processing system Others sought bank loans to

keep their practices fluid Seven thousand other

nonprofits and providers had not been compensated properly

State’s finances were threatened

Overpayments were made totaled $9 millions

The disaster cost the state an additional $30 millions

Medicaid was behind on $50 dollars worth of payment

What management, organization, and technology factors caused these

problems? Management

Decided to develop an entire system from scratch using unproven technology

Rejected an option to outsource claims processing systems to a service provider such as EDS

Hired a vendor (CNSI) with no experience in developing Medicaid claims systems because they were the lowest bidder ($15 million dollars)

Not having a Medicaid expert to lead the team

Chose not to follow CSNI’s recommendation to re-enroll all providers as required by the new system

What management, organization, and technology factors caused these

problems?

Organization There was not enough staff to

handle customer service Team members on the project

were not properly trained and worked on the same parts of the system

No consultation with Medicaid experts on staff at the Bureau of Medicaid service

The team took shortcuts due to the deadline

End-users were not trained on how to use the new system

What management, organization, and technology factors caused these

problems? Technology

CNSI had no experience working with Medicaid systems

The programming was planned on J2EE, which did not match the legacy code from the old system

No backup or parallel system to support the deployment

The system was not comprehensively tested

Describe the steps you would have taken to control the risk in the IT modernization project

Use internal integration tools Formal planning and control tools

for documenting and monitoring project plans

Manager with strong technical and project management background – team members highly experienced

Actualize needed change management New distributions of power and

authority lead to resistance Run a parallel strategy along with

a pilot strategy with a phased approach Parallel strategy would of avoided

claim problems Pilot strategy would of discover

operational problems Phased approach would of got the

IT upgrade moving forward.

Damn it Jim, not aProject Manager!

Describe the steps you would have taken to control the risk in the IT modernization project

Rework and resubmit RFP Only two respondents with a large

quote gap should have been a sign of something amiss

Explore integration with legacy systems and explore outsourcing claims processing

Add more staff as problems developed A project this size should of

formulated out to a larger staff

If you were in charge of managing this project, what else would you have done differently to increase the chances for

success?• I would go with a designer that

already had created a similar successful system for another state.

• • Appointed a Medicaid expert to work

with the designer full-time from the beginning.

• Invested not only the set aside funds for the project, but appointed the key people who were not only capable, but were also responsible for the project’s success.

• Allocated the appropriate experts of people to be “on call” when the vendor had questions about how something worked.