Thursday, August 29, 2013

NYS Early Intervention Program makes up more rule changes as they trip along


Here is an illustration for providers in the NYS Early Intervention Program that clearly illustrates the selfish orientation of thinking that is driving decision making on a central level at the Bureau of Early Intervention.

Exactly two months and two days ago, the Bureau of Early Intervention instructed providers to "accept claim amounts proposed by the insurer as payment in full from the insurer for the claim which are lower than the State-established EIP rate."  Although they explained that this would not impact payments from escrow in the short term, we explained that accepting these payments in this way would be problematic because of the long term intent of having providers accept payments directly from insurers.

TODAY we received a DIFFERENT set of instructions from the Bureau of Early Intervention that states:

Dear Colleague:

The Department is aware that insurers or insurer clearinghouses (Multiplan, Omni Plan) have sent expedited agreements to EI providers in response to claims submitted for EI services. The expedited agreements asked providers to accept claim amounts proposed by the insurer as payment in full from the insurer for the claim, which is lower than the State-established EIP rate.

DFS has recently informed the Department that commercial insurance plans that are regulated by New York State should not be sending these agreements to providers who submit claims for EI services. The New York State Prompt Payment Law requires that claims be processed within 45 days or the insurer could incur a violation and payment of additional interest.

Providers should no longer be receiving expedited agreements from insurers that are regulated by New York State. In the event that a provider does receive an expedited agreement from an insurer that is regulated by New York State in the future, the provider should not sign the agreement. Providers can determine whether or not the insurance plan for a child is regulated by New York State by accessing the child’s home page in NYEIS and by selecting the insurance coverage option, and select view for the insurance company and policy information. If this information is not available in NYEIS, the provider should work with the child’s service coordinator to obtain this information. The service coordinator and/or the municipality are responsible to ensure that current insurance information for each child is updated in NYEIS or in KIDS.

So in other words, because the BEI crammed this system in at the 11th hour and never did any of the proper planning to enroll providers into networks, insurance companies are doing what they do by trying to get providers to sign expedited agreements which essentially helps the insurance control costs by clearing the claim and processing it as an 'out of network' situation.  That gets them off the hook for making a payment at the contracted rate.

The evil part is that when we see the insurance companies asking providers to accept negotiated rates the BEI is all over it and telling providers to go ahead and sign up - never telling providers what the long term impacts of those actions will be.

But when BEI figured out that signing the paperwork means that the BEI will get less than what they are entitled to, look how quick they are to issue guidance telling providers NOT to sign the paperwork!

 I understand that the complexity of this runs so deep that only medical billers might understand the full nuances of PPOs, negotiated payments for out of contract work, and similar posturing in insurance-provider relations.  What providers need to walk away with is the knowledge that if it serves the BEI they will take care of themselves.  If it is an issue that at the moment they don't think will matter to the BEI then providers are on their own.

This issue is prima facie evidence that they have no idea what they are doing over there.  Any provider that places trust for something as important as billing in the hands of this system is foolish - and we are all forced into a foolish situation because of the heavy handed way that the contracting came down and the absolute lack of meaningful stakeholder participation in making these transitions.

We would have all been better off billing the insurance companies ourselves and having the balances waterfall down to the escrow account as the payer of last resort.  That would have been a tough potato for the provider community to swallow, but I absolutely promise that it would have left this system in a much more favorable position than where it is today.

In the meantime expect more guidance from the early intervention program as they "learn" about medical billing. It is all happening on your backs, but they understand that you are not organized and you have no powerful voices so they can get away with just about anything.

Friday, August 23, 2013

New York State Early Intervention: Roadmap through the end of 2013


My email box is flooded from colleagues asking about the NYS Early Intervention program - so I thought I would lay out the likely path toward the end of 2013 so people can plan appropriately for what lies ahead.

I also have a roadmap through 2014 and 2015 which will be published as a part of this series.  Stay tuned.

Fall, 2013: The already stressed EIP will continue to come apart at the seams.  Payments to providers will continue to be excruciatingly slow and complex.  Even more providers will leave the system creating even longer waiting lists for children and families.

There will be no immediate 'fix' because the legislature is out of session until January.

Governor Cuomo and his administrative team will continue to blame the insurance industry for the problem and will refuse to acknowledge their own roles in creating the mess.  This will lay the groundwork for insurance reforms that will be introduced next year in the Governor's Budget.  The State will stick to the party line of offering 'safety net payments' and as providers go out of business they will claim that they could have taken advantage of the  safety net payments that may or may not be a loan depending on what day of the week it is at the DOH.

In mid-Fall, with much fanfare, the NYS DOH will say goodbye to their interim fiscal agent.  However, workers at James McGuiness and Associates will not have to fear for the immediate loss of their jobs because it will take months to get all of the payments processed through their systems.  Additionally, they will fade back into obscurity and will revert back to their roles as billers for County preschool payments.

Sometime in the Fall the new State Fiscal Agent, Public Consulting Group, Inc., will introduce new early intervention billing systems that will tie the provider community up in knots.  With all the negative press, they might consider removing the smirking dude on their website with the caption that reads "Our team has extensive experience with the full range of payment models and techniques that drive performance and reduce net state/municipal costs for health care services."  They might not have to remove it though because most early intervention providers spend their time appropriately attending to the needs of children and have not yet noticed the smirking dude on their website and what he is really saying.  If enough people read and think about what Public Consulting Group, Inc.'s expertise really is they might link it to the smirking dude on their website and that could be an image problem they want to avoid so we will see if that gets changed.

Since people might not notice the smirking dude on their website they might not also notice that NYS tax dollars are going to be paid to the Public Consulting Group, Inc. so they can increase jobs in.... TENNESSEE?  Yes, that's right - the call center support for the NY Early Intervention Program is hiring people in Nashville, TN.  Someone might want to make a call to Governor Cuomo about that because it is unfortunate that NYS would contract with someone who takes our tax dollars and then promptly applies them to the unemployment problem in Nashville.  Of course that link will be dead as soon as they hire the folks for the Nashville office - so go check it out now please.

Late in the year the provider community will receive tax guidance on how to process the loan money that is not really loan money.  Then it will become crystal clear that it is really not loan money because loan money is not taxed in NYS but your safety net payments sure will be.  Providers will gnash their teeth and regret ever taking the loan money that is really not loan money because they will find themselves in a very unfortunate tax situation.

As things continue to boil over the next couple months it is extraordinarily unlikely that there will be legislative action because that would take Governor Cuomo calling for an emergency session.  He can't take the risk of having legislators talking about the Early Intervention meltdown (reference the next post on Roadmap through 2014 - coming soon - hint: it has to do with elections) so unless he can find a way to control the spin or link it to some other heroic action on Upstate flooding or maybe the Women's Equality Act that the Senate did not pass it is much more likely that he will put on a SuperMan suit sometime in the Fall and announce yet another form of administrative financial support to prop up the program 'while we give the State Fiscal Agent time to get on its feet' or something like that.  He will make some speeches and people who know better will make statements like 'You can't put band aids on bullet wounds' but he will find enough sycophantic reporters to print that he has saved the day that he will remain unscathed if not heroic.  Then people will go into winter hibernation mode with visions of sugarplums and possible legislative proposals in their heads for the 2014 session.  Like I said - more on that soon.

Bottom line: good things are not on the horizon.  You heard it hear first.

Monday, August 19, 2013

Thursday, August 15, 2013

Early intervention providers: Look the 'Gift Horse' in the mouth please.

I received this in email today:

Dear Colleague:

The NYS Department of Health (Department) is offering a one-time State safety net payment to Early Intervention providers, and will not proceed to implement the Preliminary Escrow Payment (PEP) proposal due to insufficient county participation.  

State safety net payments will be calculated as seventy-five percent of the value of claims submitted to insurers, with the exception of the medical assistance program, in the period April 1, 2013 through July 29, 2013 for which no known payment or denial has been received.  The State safety net payments will be reconciled commencing on October 1, 2013 by assigning to the Department twenty-five percent of each early intervention payment payable from the escrow account until such time as the State safety net payment is fully recovered.  The safety-net payment is a one-time payment made by the State.  All claims submitted by the provider, including those submitted to insurers in the period April 1, 2013 through July 29, 2013, will continue to be processed and paid in the normal course.  

Providers who wish to participate in the State safety net payment must execute an amendment to the Provider Agreement held with the Department.  If you are interested in participating in the safety net payment and would like a Provider Agreement Amendment sent to you, please e-mail the Bureau of Early Intervention at Provider@health.state.ny.us 

We request that you included in the body of the e-mail

“I request that the Department send to me the Provider Agreement Amendment in relation to the State safety-net payment and I authorize the Department to send the Provider Agreement Amendment by UPS overnight mail/signature required.”

Please include in the e-mail your full name, mailing address, and phone number.

The Provider Agreement Amendment must be signed, notarized, and returned before the State safety net payment can be issued.  Provider Agreement Amendments should be returned to the following address:

Bureau of Early Intervention
ESP Corning Tower, Room 287
Albany, NY  12237-0660
Attention: Provider Unit

The Department is requesting that you return the Provider Agreement Amendment as soon as possible after receipt to ensure timely safety net payment.  The Department will not accept requests for Provider Agreement Amendments after August 31, 2013.
Please contact the Bureau of Early Intervention at 518-473-7016 if you have any questions. 

Just so everyone is clear - THIS IS NOT A PAYMENT.  This is a loan for the money that is already owed to you.  You will have to pay it back - and there is no accompanying fix for the mess that they have made of the billing and claiming system.

How many people are in a work agreement where they have to take a loan from the other party as payment for services rendered?

Also, just like the original Provider Agreements, these are being crammed down the throats of providers with a demand for less than a two week turnaround.  That means that providers who are currently owed tens of thousands of dollars (and in some cases even more) will have to somehow make the legal determination that the agreement is legitimate and will have to make the accounting determination that it makes sense for their businesses - all with very little opportunity to study the issue fully.

As this is a "one time payment," how will this address the problem moving forward?  This 'solution' is another nail in the coffin of the Early Intervention Program because it does not solve any of the problems with the current system.  Will we see another LOAN to cover the period from August through November???  I can guarantee that there is no fix in the works that will make payments suddenly start flowing through this system.

Providers should be given adequate time to study the legal and accounting implications on our businesses before accepting such an agreement - and our State government should stop trying to throw band-aids on a gaping wound that they created.

Wednesday, August 14, 2013

Note to politicians: Grandstanding on important policy issues does not win votes.

All press is not good press.  Especially when people get distracted from what the primary issues are.

In tonight's Capitol Confidential post there is a report that is headlined: "Therapists want to get paid, Tedisco sees 'War on Women.'"

The headline I would like to see is: "Children go without important therapy as NYS decimates Early Intervention Program."

A parallel example recently was the announced closure of O.D.Heck.  This announcement generated conversation about the plight of union jobs.  What got lost in the shuffle was the important human rights policy of de-institutionalization and the very real fact that there are problems with maintaining appropriate standards of care when we warehouse people who have disabilities.

How do concerns with the early intervention program degrade into a headline about the 'war on women"  and grandstanding on some cause du jour???  The cheapening and coarsening of our policy discourse in this way moves us farther away from being able to solve real problems.

It is true that most of the early intervention providers are small woman-owned businesses.  However, conflating the early intervention program as an opportunity for some political haymaking with 'war on women' statements is farcical.  Similarly, showboating your position on restoring OPWDD funding does not have anything to do with the early intervention program.

In many ways this kind of coverage makes me glad that I missed the rally today.  I would have been there trying to raise awareness about the malfeasance that destroyed the program and suddenly I would have been in front of a couple politicians who make statements that sound like raw opportunism.

I will give the politicians a chance for a pass - because it is always possible that they were appropriately on-message about the real concern and a reporter simply focuses on some bizarre aspect of the message that doesn't quite fit.  Maybe writing about the 'war on women' generates blog hits?  If this reporter accurately reflected the tone and content of political participation today then we clearly have a problem.

Here is what we need to stay on message about and this is what we need to see reported:  As a society we make decisions and choices about what degree of social safety netting we will provide with vulnerable populations.  It is reasonable to have debates about how much netting we put down.  A question that we need to answer is - 'how robust of an early intervention program do we need and how robust of an early intervention program can we afford?'

Specifically, we should have debates about who should be in the program.  We may come to decide that we can't have the largest program because we just can't or don't want to afford it.  Maybe only children with certain levels of developmental delay or only those with severe diagnoses should be seen in the program.  Then we can refer other families to private providers or other resources.  That is a reasonable debate to have.

It is also reasonable to look for ways to distribute the costs fairly.  It is absolutely reasonable to enact cost sharing and to put some of those costs into the private insurance market where they rightly belong.

What is incorrect is to leave the program as-is and pretend that we can have unending and balooning entitlements.  It is also incorrect to be afraid to have that conversation and then control the cost and size of the program by back-door manipulation of insurance payments to providers.  Then the bureaucrats hide in their offices in Albany and release statements that 'it is the insurance company's fault for not paying.'  That is the most disingenuous set of statements I have heard lately.  The government was fully informed and advised of the municipal inability with medical billing - and they took it on anyway and the result was absolutely predictable.

Then as people scream about the end of the program, we have opportunistic pols talking about the 'war on women.'

This is how we are failing.  We need to elect better representatives, and then we have to encourage and enable them to have the correct conversations.  We have to eliminate their culture of pandering and grandstanding.  Then we can try to learn how to have real policy debates and make some real progress on our challenges.

Based on the reporting about politician's statements that I am seeing coming out of the 'rally' today - it seems that we still have a long way to go.


Saturday, August 10, 2013

George Barton: Birth and early influences.

George Edward Barton was born on March 7, 1871.  That is a rather dry fact about one of the important founders of the occupational therapy profession - so what can be done to help give it context?

Context provides dimension - and if we want to learn a little about George Barton it might be helpful to know a little about his history.  His parents lived in Boston, Massachusetts.   His father was Edward H. Barton, the Secretary and Treasurer of the South Boston Savings Bank.  His mother was Rebecca Duncan (Boynton) Barton.

It was difficult to find other information about George Barton's parents, but a rather unexpected pair of portrait photographs were contained in some of his possessions that led me through this investigation.  Here is the first picture:


I recognized this photograph; it is an original portrait of Louisa May Alcott - but why would it be in the possession of George Barton?  Louisa May Alcott was born November 29, 1832 and she died on March 6, 1888.  That would have made George Barton only 17 years old when she died, so they certainly were not contemporaries.

This is a second (smaller) original portrait photograph that identifies the photographer as Augustus Marshall.  A quick search led me to the fact that this was taken in 1870 and perhaps she was not happy with this photographer, writing "His pictures are vile."   (Shealy, D. [ed.], 2008).





















As I continued my search I learned that Louisa May Alcott was a prolific letter writer and I was able to find some letters that she had apparently written to a 'Barton' family (Shealy, D. [ed.], 2008).  I contacted Dr. Shealy about these photographs and he was extraordinarily helpful in providing some additional information:

Edward Henry Barton and his wife were neighbors of Louisa May Alcott and her sister May Alcott, when the two lived at a boarding house at No. 43 Pinckney Street in Boston in late 1869 and early 1870.  I know little of the the couple; however, they are mentioned a number of times in my edition Little Women Abroad: The Alcott Sisters' Letters from Europe, 1870-1871 (U of Georgia Press, 2008).  LMA, while in Europe, wrote to Mrs. Barton on 9 January 1871: "I shall come home as early as it is safe, & one of the first visits I make will be to my Bartons.  I hope I shall find a cradle in the house & a rosy little Edward Henry in it, ready to welcome his Aunt Weedy" (pg. 269).  From LMA's words, it appears the child is about to be born or was just born.  Since you indicate George Edward Barton was born in 1871, it appears likely he was the son of Edward Henry Barton.  That would be my first guess.  If not, he is clearly a relative.  I never located any information about the Bartons in my brief research into their lives.  However, I would suggest you use Ancestors.com or other similar websites to locate them.  You could do a search of births in Boston for 1871.

By the way, LMA's photographs, especially the Marshall one (a fairly common one), are mentioned several times in these letters in relation to the Bartons. You might find these references useful.  The index will guide you to them. (D. Shealy, personal communication, 7/31/13).

It seems that the 'rosy little Edward Henry' that Louisa May Alcott was thinking about two months before his birth was actually George Edward Barton!  I have been able to confirm dates, residences, and family members through genealogy databases and census records from that time period.

I was not able to find any other references or letters linking Louisa May Alcott to George Barton, but apparently she was important enough to him that he kept her photographs among his possessions.

Only speculation is left - but as I will show in future posts, George Barton was a Renaissance Man and had very broad intellectual interests.  It is possible that he was influenced in direct and indirect ways by Louisa May Alcott, who was obviously dear enough to him that he kept her photos.  We know that Louisa May Alcott was schooled by her father Bronson Alcott - one of the original Transcendentalists - and also spent time in the libraries of Ralph Waldo Emerson and Henry David Thoreau.

So these are the social circles of Edward Henry Barton and then his son George.  These social circles were the culture that he was immersed in and may have influenced his thinking.  It is likely that George Barton, through his family affiliation with the Alcotts, would have been very familiar with Emerson's (1837) thinking:

We will walk on our own feet; we will work with our own hands; we will speak our own minds.

This was a basic belief in American self-reliance.  It was a core philosophy of Transcendentalism.  It is just speculation, but it sounds like a foundational concept that might have been used to inform George Barton's thinking about occupational therapy.

References:

Alcott, L.M. and Alcott, M. (2008). Little Women Abroad: The Alcott Sisters Letters from Europe (1870-1871) D. Shealy, (Ed.).  Athens, GA: University of Georgia Press.

Emerson, R.W. (1837, August 31). The American Scholar.  Speech presented at the Phi Beta Kappa Society, Cambridge, MA.





Friday, August 09, 2013

NYS Early Intervention botches billing for commercial insurance too


Today we received notification that some of our early intervention families have been sent our payments for the services we provided to children.  The payments are not supposed to be directed to the families - they are supposed to be directed to the providers or to the State for processing.

Based on our private billing experience as an outpatient clinic, it is uncommon for insurance companies to send reimbursements directly to enrollees, but it happens.  Most of the time when the insurance company does this the family hands the checks directly to us.  Unfortunately, some people don't understand what the checks are or in some situations they just view it as a 'payday' from the insurance company and they keep the payments for themselves.  We eventually learn about this after we call the insurance company after a period of non-payment and they tell us that the claims were paid.  Then we are in the awkward position of calling the patient and asking them to pay the funds that the insurance company provided to them.

Thankfully our honest and forthright early intervention family called us immediately and told us about the 30 checks that they received for services we provided.  What will be fun now is to de-tangle the mess because some of the payments are for services my agency provided and others are for services provided by others.  Additionally, there will need to send the information back to the Interim State Fiscal Agent because the payments made were only partial payments.

We also reassured the family that the insurance company was incorrect and that the family is not responsible for co-pays and deductibles.

So, it seems that commercial insurance was the last of the payments that were not being processed, but now we see that even that part of the system is horribly broken.

Congratulations are in order to NYS Governor Andrew Cuomo and Bureau of Early Intervention Director Brad Hutton.  They have destroyed the billing and payment system for this important program from stem to stern.

Thursday, August 08, 2013

For Governor Cuomo: A lesson about the nature of the insurance industry

I have used this space as well as our Facebook page to chronicle the ongoing problems with municipal takeover of health care.  The problems with billing and payments to health care providers has gotten a lot of press lately and Governor Cuomo and his administration are taking some very well deserved lumps for their inept management of the Bureau of Early Intervention.

There is an apparent inability to understand the nexus of their legislative and regulatory fiats with the corresponding impact on service delivery.  All we get from our government is statements that the problem lies with private insurers that have failed to pay their share of the program's cost.

Albany intended to share costs, but they do not intend to share responsibility for their actions that contribute to the problem.

What they fail to understand is that when the government burdens a private entity you can count on the fact that there will be push-back from the private entities.  Failing to take this into consideration has been a recipe for disaster.

As a stunning example of the push-back from insurance companies, I received a letter from United Healthcare today that announces a new policy for their Medicaid Managed Care lines.  Under the new policy effective September 1st 2013, physical/occupational/speech therapy for children under 21 will now require authorization after the 12th visit.  Previously, there was no authorization policy for children.

What is interesting is that there can be no benefit limit for children under 21 according to NYS Medicaid rules.  Pragmatically, this will serve to further 'gum up' the process of providing ongoing therapy for children who have developmental disabilities and it can cause short term delays and interruptions in service provision.

Maybe United Health Care is hoping no one will notice that their policy contradicts NYS Medicaid regulations?  I called their Provider Relations department and they had no knowledge of the new policy that was mailed out to providers.  It is possible that they found some new wrinkle in the regulations that they could exploit - I would not be surprised.

Here we have a situation where government created a very liberal benefit that it could not afford, and then mandated cost sharing with private commercial insurance that they did not want to pay for.  Rather than create a context of reasonable discussion about what we could or could not afford as a society, now we are stuck with mandates that contribute to a disastrous failure of our health care systems.

Both government and businesses are complex entities, and studying municipal and market forces that impact service delivery is also complex.  Despite the complexity, we should still expect to have governmental administrators who understand how these forces interact.  When that doesn't happen (as is the norm), we have the problems that we see with the early intervention program.

Government is making up rules and new mandates; the insurance companies are responding in kind.  Families who require these services are caught in the middle.

Failure to understand how these forces interact is entirely the fault of government.  These are basic issues - so here is a  basic lesson for Governor Cuomo and his administration to think about the next time they come up with new rules for the insurance industry:


Monday, August 05, 2013

More transparency to help in analysis of the NYS Early Intervention Program billing problems

On 7/15/13 I posted about how the interim State Fiscal Agent appeared to be trolling NYS Early Intervention Service Providers for private business.

In the interest of transparency, I wanted to update that issue.

In the email I referenced how UNYEIP stated that Director Hutton would write financial hardship letters for providers who have not been paid.  I attempted to verify this and the Bureau of Early Intervention would not admit that they would do this; this is the email that I received from them:

I was not able to find out anything further about hardship letters.  However, BEI made the announcement below on Friday [referencing how providers can borrow money that the State owes them - cja editorial comment].  Counties must sign and return an agreement to the Department if they choose to participate in the PEP.  Providers must also sign an agreement and return it to the Department if they wish to avail themselves of the PEP if the municipality is participating.  All information regarding the PEP, including which municipalities are participating, is being posted on EIBilling.com as they return their agreement.  The provider agreement should already be available on EIBilling.com by now.  If you have further questions about the PEP, please address them to BEI@health.state.ny.us.  Thanks.

I found this interesting.  Maybe it was their intent to replace the hardship letters with a loan program.  Counties were not too thrilled with the Bureau of Early Intervention's "loan program" because it basically was just another mandate on Counties - and that is rather ironic because the whole point of the SFA was as a point of mandate relief. 

In Washington County, Salem supervisor Seth Pitts (a member of the county board's Health Committee) had the best statement I have heard in a really long time.  He was quoted in Poststar.com:

“These rocket scientists in Albany come up with this brilliant idea and then these boobs want us to pay for it.”

Anyway, I received a response from Chris Weiss about the letter that seemed to be trolling.  He apparently works for the interim SFA, although in some other division.  This is what he told me about his letter:

Mr Alterio,

I'm sorry to confuse you.  I do not work with eibilling.com.  

As I stated, I work with providers such as yourself and have been working with them to determine the most efficient daily procedures for EI.  That work led to the information I sent to you and many others (who don't use my software or pay anything for that information).  I'm sorry that you didn't find it as useful as most people I've talked with have and will remove you from my mailings of any future information / suggestions.

Apologetically,
-Chris Weis

 He took the time to cc: his email to the head of the company.  I was not impressed with the half-hearted commentary about how he thought he was sending out useful information, so I sent it all to the Bureau of Early Intervention because I think they need to take this seriously.  Today I received this email from the Bureau of Early Intervention about my concerns that the interim State Fiscal Agent appeared to be trolling for business:

We are responding to your e-mail below.

We will bring this issue to our director’s attention and address it as they determine.

Thank you for bring this to our attention.

Not terribly specific or formal, but I guess they received my concerns at least.

This is all relatively important for the public to be aware of.  Over the last week there has been a surge in press and commentary on Twitter and Facebook about payment problems in the Early Intervention Program.

While providers are waiting to be paid for services that they provided months ago, the interim SFA seems to be trolling for ancillary business and the Bureau of Early Intervention is looking into it.  I always find it helpful to juxtapose reality of what is not happening (getting paid) with the reality of what appears to be happening (advantaging relationships and email distribution lists  of NYS for promoting your products and presumably attempting to boost sales outside of interim SFA responsibilities).

As providers and families continue to experience difficulties with the EI program, this is the kind of important information needed to help understand the motivations of the players involved.

I welcome any involved parties to submit information to me if I have misrepresented their email communications to me in any way.  Transparency is only good when it moves in every possible direction, and I welcome it.