A Sick Medicaid System

In: Business and Management

Submitted By shamikabnks1
Words 1201
Pages 5
A Sick Medicaid System

August 5, 2012

Maine Department of Human Services (DHS) believed that they needed a new Medicaid system so that information could be safer, accurate, and provided more functions. This new system needed to be updated with the new HIPAA requirements. DHS managers reasoned that building a new system would be easier and less expensive to maintain than upgrading and maintaining the old system (Oz, 2009). In 2001 DHS put together a proposal. They received two offers. DHS chose the lowest bid from a company called CNSI. CNSI had no experience with a Medicaid system. When trying to build this new system there was very little communication between CNSI and the medical experts. In 2003 the new governor John Baldacci merged the Department of Behavioral and Developmental Services with the Department of Human Services in the new Department of Health and Human Services (Oz, 2009). In doing this the new system was a disaster. The claims were being denied and medical providers had to take out loans and some had to close their businesses because of no payments. DHHS fell so far behind due to the system they had to hire more experts. Instead of the system costing $15 million they had to pay out $70 million and they were six years behind.
Were there any factors that contributed to the project failure which were not the fault of the project team and its leaders? There were several factors that played a roll in the project failure. The first issue was the fact that they only had two RFP’s and the states head of procurement that chose the lower of the two bids. When making the decision he/she didn’t hold in account that they didn’t conduct any type of research for either company, they checked no references, they checked no past projects of CNSI, and left no room…...

Similar Documents

Medicaid Management Information System

...Information system (Medicaid Management Information system) I would like to pick up MMIS (Medicaid Management Information system) as my topic today. MMIS is coupled with multiple entities like claims, provider, client, PA(Prior Authorization), TPL(Third Party Liability), DRB ( Drug Rebate) subsystems. First of all client enrolls into the state medicaid system. When the client goes to the provider, they will verify the insurance and claims to it. All this data was collected from frond end screens, paper, fax, imaging and stored in Oltp system. The data is then moved to ware house by using ETL tools like datastage, informatica etc. The same data will be used to reporting purposes by using tools like cognos, business objects etc. The components of the information system are: 1. Hardware: It is equipment that processes the data for information and it includes input, output, storage and communication devices. Typically in MMIS environment we need to figure the # of server’s needed, capacity, storage before kicking off the project. 2. Software: software is a set of instructions written in a specialised code that convert data into information. Need to decide what COTS products need to be used for the project. 3. System Policies: It governs the operation of a computer system. Set some system policies for securing the data, testing policies etc. 4. Data: Data was used by the programs to produce useful information. Data are stored in machine readable form until the computer......

Words: 278 - Pages: 2

Medicaid Programs

...Medicaid Programs By: S. Nichole Sewell AJS/522 - FINANCE AND BUDGETING IN JUSTICE AND SECURITY Instructor: HENRY PROVENCHER Medicare is a national social insurance program, administered by the U.S. federal government since 1965, which guarantees access to health insurance for Americans ages 65 and older and younger people with disabilities as well as people with end stage renal disease (Medicare.gov, 2012). Medicare is a program that offers everyone a well defined benefit that includes different hospital parts. The Medicare parts are: Part A, Part B, Part C & Part D. Part A is known as hospital insurance. This part covers medical necessary such as hospital stay, nursing home, home health care and also hospice care. Medicare Part A is free to people who have worked and paid in Social Security for at least 10 years. There will be a monthly premium charge if you have not worked for at least 10 years and paid Social Security taxes. Part B is medical insurance that covers things such as doctor visits, medical equipment and various other forms of other outpatient services. Part B also covers mental health care and ambulatory services. To receive the Part B medical insurance you have to pay a monthly premium. Part C is the portion of your policy that allows private insurance companies to cover your medical expenses.......

Words: 1957 - Pages: 8

Medicaid Funding Poilcies

...enrolling participants in HMO. I understand that we have some key questions must be addressed and that we must justify our position on either economic efficiency or equity grounds. Outlined below are some of the questions that must be answered in order address this issue properly. Is Medicare in a state of crisis? Are you aware of the various policies that are being enacted from each state to state regarding the qualification of Medicare? Medicare is funded by the federal government and each state is responsible for operating the Medicare program as well as the local Medicaid programs. However, premiums have increased for Medicare and also, the coverage has changed in the past few years requiring people to purchase additional supplemental Medicare policies - this is difficult for elderly that have fixed incomes. If the elderly are unable to purchase Medicare, they will go uninsured. The Medicare system is double-funded. It is funded by the taxpayer (federal dollar) as well as the premiums being collected. But, in being double-funded, the coverage is still not as high as most private insurance companies making them appear with less quality. Are radical measures necessary to preserve the program? This is a very interesting question and you will have to take a more subjective approach to answering it. I don't believe there are radical measures that must be taken to preserve the program because it is funded through two divisions - the federal government (taxpayer)......

Words: 1692 - Pages: 7

Sick Leave

...Case #8 - Sick Leave Steve Tobias MGT 470- Conflict Management and Negotiation Colorado State University – Global Campus Dr. Ernesto Escobedo September 3, 2013 Background Three foreign Assistant Language Teachers (ALT’s), Mark, Suzanne, and Kelly are employed in a teaching program titled Japan Exchange and Teaching (JET). The Japanese government developed JET in an effort to better the English language education in Japan through the use of international teachers. It was also hoped that the program would promote an understanding at the local level of the importance and value of the differences between various cultures. Any differences that presented themselves between the ALT’s and their employers would be heard by the Conference of Local Authorities for International Relations (CLAIR). An issue however, was that, by agreement, CLAIR would only become involved if the employer would not or would not resolve the problem itself. Issue In this case study, Kelly and the other ALT’s had taken two days off for being sick. The ALT’s were directed by their boss Mr. Higashi to get a doctors note before returning to work and were told they could not use sick leave, instead they would have to use accumulated vacation time for their absence. Mr. Higashi explained that the work ethic is different in Japanese workers and they feel guilty missing work generally and especially......

Words: 958 - Pages: 4

Expansion of Medicaid

...Expansion of Medicaid Name School Abstract On March 23, 2010, President Obama signed the Affordable Care Act (ACA) into law, allowing all Americans access to affordable health care. Despite the urgent need to provide health care to all Americans some Governors and elected Congressmen continue to debate over the necessity to expand Medicaid and the ACA. The Supreme Court on June 28, 2012 ruled in support of the ACA by upholding the individual mandate which require Americans to have health care insurance. Americans without health care insurance, because of this new health care policy will be able to either purchase insurance through the exchange market or through the expansion of Medicaid. Some states are against the expansion of Medicaid even though the government will fund 100% of the program for the first 3 years. The states that decide to opt out of the Medicaid expansion will heap some negative impact on several stakeholders. The ultimate goal of the ACA and the expansion of Medicaid was to provide quality health to the many uninsured. Expansion of Medicaid The implementation of an important component of the Affordable Care Act (ACA) is the expansion of Medicaid. The expansion of Medicaid ensures health care coverage for children, poor people, disabled people and some elderly citizens. Unfortunately, 20 states have decided to opt out of this policy leaving access to health care unavailable to millions of needy people. It remains unclear why so many...

Words: 2326 - Pages: 10

The Evolution of Medicaid

...Evolution of Medicaid Genesis65 HCS/310 April 19, 2010 Barbara Sinacori, RN, MSN, CNRN The Evolution of Medicaid Prior to 1965, the poor elderly in the United States were left with little options when it came to accessing and paying for preventative health related services. As a result, many of the poor in the U.S. went without routine health care or treatment for known illnesses. In response to this growing issue, the Federal government, under the direction of President Lyndon B. Johnson and in conjunction with state governments, established the Medicare program on July 30, 1965 through Title XIX of the Social Security Act (Centers for Medicare and Medicaid Services, 2010). Along with passage of the Medicare Bill in 1965, Congress also passed an insurance program known as Medicaid that would provide health care insurance for various groups of disenfranchised U.S. citizens. This paper will briefly discuss the evolution of the Medicaid program and examine how Medicaid has influenced the current health care system in the United States. The ever-rising cost of health insurance has prohibited many businesses from providing health insurance to their workers, effectively leaving millions of Americans uninsured or underinsured. According to the U.S. Census Bureau (2007), “The number of people without health insurance coverage [in the U.S.] rose from 44.8 million (15.3 percent) in 2005 to 47 million (15.8 percent) in 2006.” Medicaid......

Words: 1112 - Pages: 5

Medicaid in Texas

...Medicaid is the State and Federal joint venture that provides medical coverage to the eligible individuals. The purpose of Medicaid in Texas is to improve the health of people whose income and resources are insufficient to pay for health care. The Texas Health and Human Services Commission's (HHSC) Medicaid Office is responsible for statewide oversight of Texas Medicaid. The mission of the Texas Medicaid program is to improve the health of Texans by emphasizing prevention, promoting continuity of care, providing a medical home for Medicaid recipients and ensuring that each recipient can receive high quality, comprehensive health care services within the community. (6) Medicaid serves primarily low- income families, children, caretakers of dependent children, pregnant women, cash assistance recipients, people aged 65 and older, and adults and children with disabilities. Medicaid pays for acute health care (physician, inpatient, outpatient, pharmacy, lab, and x-ray services), and long-term services and supports (home and community-based services, nursing facility services, and services provided in Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICFs/IID)) for people age 65 and older and those with disabilities. Texas Medicaid provides major portion of healthcare services through managed care model. (1) There are basically four Medicaid programs in Texas. The type of coverage an individual gets depends on......

Words: 1829 - Pages: 8

Sick Leave

...confident that she knew what to expect. After a few months working there, Kelly had gotten the flu and called her boss notifying him that she would not be able to go to work for a couple of days. Her boss was aware that foreigners are known to call in sick to extend the length of their weekends so he asked her to get a doctor’s note. When Kelly returned to work, she found out that her vacation time was being used for her time out while she was sick. She discussed this issue with her employer but the he tells her that it is out of respect that employees in Japan use their vacation time when or if they take a sick leave. Kelly does not feel that it is fair to use her vacation time for sick leave since her contract with the program clearly guarantees that she is allotted sick time. She has decided to call the head of the program and complain about her boss’s failure to acknowledge and follow the contract of her employment. The benefits of tangible can be measured in terms of money involving at company with its employees. The Contract of English Teaching Engagement that Kelly, Suzanne, Mark, and Andrea signed a standard contract given to them by the CLAIR program the stipulated hours, number of vacation days, amount of sick leave and so on. This contract stated that the JET participants would only work Monday thru Friday until 5:00 p.m. and did not mention anything about working on Saturdays. Working over time was not necessary for the participants. The following are the......

Words: 1259 - Pages: 6


...Medicaid as we know it is a critical source of health coverage for many people especially senior citizens, and people that has a disability. It is vital to those who are in dire need of being in a nursing home and other long term care as well as their families. There has been numerous times where there have been threats to cut Medicaid so severe that it could possibly cripple the program and put all its enrollees at risk. Medicaid provides a huge proportion of the revenue for many health care facilities including Krona’s community hospital. In order for things not to get worse they must be able to protect the pay rate for services that are being provided as well as services that are being covered by the rate. Most healthcare facilities, will more than likely be affected by the cuts if Medicaid. Medicaid is a very important source of revenue for most medical centers including Krona’s community hospital. The impact of Medicaid cuts can’t be overstated. Medicaid cuts affects everyone in some form or another, it affects the patients, providers, families as well as the entire economy. There have been so many changes with Medicaid in the last few years that the payments from Medicaid have affect the ability for medical facilities to survive with such harsh cuts bringing them down. Krona’s facilities has the choice on whether or not they want to continue to provide services for patients but they must know that if doing so they risk not being reimbursed for the services that......

Words: 283 - Pages: 2

Health Care Systems/Medicaid & Medicare

...Medicaid/Medicare Services Stella Williams Harrison College Medicaid/Medicare Services Develop a plan for the center by using clinical quality measures, or CQMs, which are tools to help track and measure the quality of health care serviced that are provided by eligible professionals, eligible hospitals that are within the health care system. These would be measures to use data that is associated with providers that are able to provide high quality care or relate to long term goals for health care. The measures would be the many aspects of patient care including: * Health outcomes * Patient safety * Clinical processes * Efficient use of health care resources * Population and public health * Adherence to clinical guidelines * Patient engagements * Care coordination By reporting and measuring CQMs in a three month or 90 day reporting period will help to ensure that the health care system is safe, efficient, effective, patient centered, timely care and equitable. According to the EHR Incentive Programs the need to report the measures will demonstrate meaningful use and receive an incentive payment so the CQMs may be reported electronically or via attestation. The CQMs are identified into core sets and they are highly recommended so the focus can be on conditions that contribute to the morbidity and mortality of most Medicare and Medicaid beneficiaries with some factors that would be recommended, the Center would have to have certain......

Words: 873 - Pages: 4


...Medicaid And The Problems The Program Faces Research Paper Introduction Medicaid is the largest health insurer in the nation, providing care to more than 50 million Americans with an annual cost around $250 billion. With Medicaid being the largest insurer in the United States, they face many problems and concerns, including limited access, low quality of care, financing and reimbursement concerns, and increased costs. Medicaid Reform is in the near future and with Medicaid’s spiraling costs, mandated managed care ought to be. The Medicaid program, created by the Social Security Amendments Act of 1965, is a partnership between the federal and state governments to provide healthcare to low income and vulnerable populations. The Federal Centers for Medicare and Medicaid Services (CMS) monitors the Medicaid program and establishes broad guidelines for program eligibility, services covered, the delivery of services, and the quality. Each state administers their own program with specific eligibility standards including the type, amount, duration, the scope of services covered, and the payment levels for services provided, (Perlino, 2010). Medicaid operates as an entitlement program making the federal government, under federal law and the budget process, obligated to pay their share of each state’s Medicaid program. The federal government matches the states spending services, varying from 50 to 77 percent depending on the state. Currently the federal government......

Words: 2045 - Pages: 9


...Audrick Willis The Medicaid program was established under title xix of the social security act of 1965 to pay for health care for individuals and families with low incomes. Applying for Medicaid benefits a person must meet minimum federal requirements of the state in which they live, also call or write the local office to request for an application. Factors that determine eligibility for Medicaid are people with low incomes and few resources who receive financial (TANF). People who receive faster care or adoption assistance under title IV-E of the social security act, Children six years of age who meet (TANF) requirements or families who income is below 133 percent of the poverty level. Pregnant women whose family income who is income is also below 133 percent of the poverty level, and infants born to Medicaid eligible pregnant women however, people who are age sixty five and over, legally blind, or totally disabled and who receive supplemental security income(SSI) are also eligible for Medicaid. Medicaid offers two types of plan fee-for-service and managed care plan. Fee-for-service plan allowed patient to choose a provider of their choice, as long as that provider accepts Medicaid. These providers submit the claim to Medicaid and are paid directly by Medicaid. Managed care plans restrict patient to a network of physicians, hospitals, and clinics. Individuals who enrolled in managed care plan must obtain all service and referrals through their primary care provider (PCP)...

Words: 559 - Pages: 3


...Budget Cuts in a Shelby County Clinic: A Case Study Rebecca manages a Shelby County clinic in Memphis, Tennessee. The clinic serves the local Medicaid population. The clinic’s budget was cut by 15%. Rebecca must determine what clinical services can be eliminated or introduced to best address the healthcare needs of the patients. In order to make the best decision for the clinic and the patients, Rebecca will use the Informed Decisions Toolbox (IDT) (Arroyo et al, 2007). Following is a case study of Rebecca’s decision making process. The IDT will be defined and Rebecca will follow the steps to make an informed decision. Her decision to focus the clinic’s efforts on early intervention, preventive medicine, STD/HIV prevention, and case management will be explained. Why the Four A’s tool is determined to be the most effective in making the decision will be addressed (Arroyo et al, 2007). Finally, the use of the toolbox and the affect on the clinic’s accountability, knowledge transfer, and becoming a questioning organization will be studied. The Informed Decisions Toolbox (IDT) The Informed Decisions Toolbox (IDT) is a set of tools that can be useful to healthcare managers when making decisions. The toolbox consists of six steps that can lead to a well-informed decision: Step 1: Framing the question Step 2: Finding sources of information Step 3: Assessing the accuracy of the evidence Step 4: Assessing the applicability of the evidence Step 5: Assessing the......

Words: 1835 - Pages: 8

Medicaid and Stakeholders

...Medicaid 1 Medicaid and Stakeholders On July 30th 1965 the Medicaid program was created to address the poor and elderly uninsured population in the United State. This voluntary program is administered on a State level but regulated on a Federal level. The Center for Medicare and Medicaid Services (CMS) is the organization that over sees the delivery, quality, funding, and eligibility of the program. Each individual State can choose how to operate the Medicaid itself. The program is design to help people with low income, children, parent of those children, pregnant women, disabled and elderly people in need of a nursing facility. Medicaid is a complex system because it is not a single program and runs differently in each State. It is a very costly system because its serves the poorer population and the long term patients. Currently Medicaid is experiencing changes on all levels. The rise in unemployment has caused an increase in applicants who qualify thus driving up the costs associated. With the passage of the Patient Protection and Affordability Care Act (ACA) the general consensus is that the Medicaid has some current issues to address before more people fall under their umbrella of services. Currently there are more than 59 million people enrolled the Medicaid system for health care. The system is expected to add nearly 16 million more people by 2019. With State governments facing a budget crisis many are looking to cut the Medicaid program. The Federal......

Words: 1078 - Pages: 5

Sick Book Report

...Billing/Book Report Jonathan Cohn’s “Sick presents case studies that demonstrate how America's current system causes even many middle class Americans serious financial or medical hardship. It lays out a history of health insurance in America and points to the record of systems abroad, particularly in France, as proof that universal coverage works. Cohn quickly dispenses with the common belief that it is the forty-plus million uninsured Americans who are the problem with our present system. It is our insurance itself that forms the biggest problem, an erratic problem that fails to provide needed health. Cohn methodically discusses each piece of the book one by one, using case histories to illustrate his points. He meet a few people with no insurance at all, a few with Medicare or Medicaid, and a few with good private policies. All are hard-working, well-intentioned, and startled that they have been punished, financially, emotionally, medically, or all three, for getting sick. What sets Cohn’s book apart from other compilations of sad stories is the comprehensive, dispassionate analysis he offers of the policy behind the tragedies. He provides a history of U.S. health insurance from the beginning up through the politicking behind Medicare and Medicaid in the 1960s, the rise and fall of health maintenance organizations (HMOs) in the 1990s, and the confused debut of last year’s Medicare Part D (for prescription drugs). I suspect that committed policy wonks might find...

Words: 441 - Pages: 2

Animation | Kahin Pyaar Na Ho Jaaye | Jock 8708