Consumer Advisory: The Root Cause of the PPL Problem
After repeated frustrations while working with Public
Partnerships LLC (PPL), a more thorough investigation as to the exact cause of
the problem was undertaken to determine potential solutions. The following
could be determined:
The issues occurring with PPL are mainly an IT and software
issue. In the background of the process to enroll a self-directed-employee, and
to get a goods and services provider paid, is a series of file/information
transfers between DDD, Molina Medicaid, and PPL. Each of these organizations
has their own software, and it is during these file transfers that errors
occur. To start the enrollment process, a support coordinator fills out a
referral form and submits it to PPL. From here, PPL sends a request to DDD for
a demographic file for the individual in order to ensure that all of the
information on the form is accurate. DDD will send the demographic file to PPL
via an XML file, and it is supposed to be imported daily into PPL’s software,
the BetterOnline system. The issue here, and also at later stages in the
process, is that the BetterOnline system has consistent difficulty importing
the XML files correctly. When a file is not correctly imported, no one is
informed, and no one examines the reason why the file was not imported. It
simply disappears from PPL’s radar until the support coordinator or family
escalates the issue. If customer service is called, they will tell the family
or the support coordinator that “we are waiting for DDD to send us information
on the individual” or “we have no information on the individual in our system,”
and to please wait another couple days. If escalated, the PPL admin will simply
ask DDD to resend the file, and it is common for DDD to send the same file
multiple times. If there is something wrong with the file, there is no way to
move forward. PPL has no ability to manually enter information into their
BetterOnline system. Information MUST be imported from a DDD file directly.
If the demographic file is imported correctly, the process
will generally go smoothly for the next few steps. PPL has become good at
emailing families/ individuals when they are ready for the next step in the
process, which is to have the “employer” and “employee” call into PPL to give
them additional information. PPL will use this information to pre-populate the
employer and employee packets, which are then mailed out to both parties. Many
of the people familiar with the old Easter Seals process have wondered why the
packets cannot just be made publicly available with clear instructions to streamline
the process. PPL’s response is that the forms are too complex and must be
filled out perfectly, so it easier to have customer service representatives
that are trained in the process take the information and pre-populate the forms
to ensure the forms are filled out correctly. Once families receive, complete, and sign the pre-populated
packets, they are sent in to PPL. PPL has been very good about processing the
packets, and then emailing the support coordinator with a billable unit rate.
From there, the support coordinator is able to enter the service into the plan,
and get the plan approved.
After this step is usually where the process breaks down.
Once a plan is approved, the service needs to have an authorization generated
in order to have it billable under Medicaid. Upon plan approval, authorizations
and service detail reports are automatically generated by DDD’s IRecord system,
and are automatically sent to all service providers in the plan, including PPL.
IRecord also automatically sends Medicaid the authorization, which will then
approve or deny it. After review, Medicaid will then send a response file for
the authorizations back to DDD. Denials are sent to DDD from Medicaid weekly,
and occur for a variety of complex reasons, such as if there is anything wrong
with the individual’s Medicaid file, they were not properly enrolled into their
waiver program by Molina, there is a lapse in Medicaid, or a random error
occurs. Although DDD is informed of denials, fixes to denials are slow and
complex, and neither the support coordinator or the individual are informed of
the issue. The payment of the approved service just falls off everyone’s radar
until someone complains and escalates the issue. As a support coordination
agency billing for over 500 individuals on a Medicaid Waiver Program, it is
common that 4-5 authorizations per month fail to generate for a variety of
reasons. One of the issues is that the Molina Medicaid software system is
extremely old and outdated.
If Molina Medicaid successfully approves an authorization
and sends it to DDD, the information is then sent to PPL via an XML file.
Again, PPL’s BetterOnline system has tremendous difficulty importing the file.
Again, if a file does not import correctly, no one is informed, and no one
examines the reason why the file was not imported. It simply disappears from
PPL’s radar until the support coordinator or family escalates the issue. If
customer service is called, their response will be “there are no authorized
units in our system” or worse “your support coordinator did not put any units
in the plan.” If the issue is escalated, PPL administrators will simply ask DDD
to resend the file, repeatedly if necessary. PPL has no ability to manually
enter any information into their system, or import the information from service
detail reports; the information must come directly from a DDD file directly.
If the units are correctly imported, PPL will send out a
welcome packet, and the service can begin; however, this can change on a weekly
basis. Even though services are often entered into plans on an ongoing or annual
basis, authorizations are only imported into PPL’s system from DDD on a weekly
basis. Even though the file imported correctly one week, that does not
necessarily mean it will continue to import correctly. There is no way for PPL
to enter in authorizations any further into the future than each week.
PPL administrators and customer service professionals all
have access to DDD’s IRecord system, which displays plan information in real
time. They are all able to see that the units are entered into the plan, and
that the plan is approved; however, unless it is imported into BetterOnline
from a file sent by DDD, nothing can be done to pay the service.
This is also the case for paying goods and services
providers. PPL’s BetterOnline system has had tremendous difficulty importing
authorization information for this service, especially if the individual
receiving the service is not already in their system for a self-directed
employee, resulting in the service not being paid. The payment for these
providers has been even more sporadic and unsuccessful than that of
self-directed employees.
In general, individuals that have difficulty in one step in
the process usually have difficulty in all of the steps in the process. It becomes
Murphy’s Law, and everything goes wrong due to an error in their XML or
Medicaid file.
Frequently Asked Questions
If this is so much of
an issue, why not just go back to Easter Seals?
The state cannot and will not ever go back to Easter Seals
for a variety of reasons. The biggest reason is that Easter Seals operated
using state only dollars, and did not have to go through Medicaid. Thus, they
were able to pay things more freely and did not need authorization numbers for
everything. They could fix issues manually or by simply cutting a check. Easter
Seals would also have a difficult time in this new system.
Why doesn’t PPL fix
its BetterOnline system?
PPL’s IT department has not been willing or able to fix the
issues that are wrong with this system. They never examine and correct the root
causes of why certain files consistently fail to be imported correctly. DDD’s
IT department has been encouraging them to do so often. The bigger issue is
that the BetterOnline system was never meant for this purpose. It is an older
system that has been adapted for this, and is not really suitable.
Why doesn’t Medicaid
update its computer system?
New Jersey has tried and failed for over a decade to update
its Medicaid system. This being said, there is an effort underway to update
this system called RMMIS, but it is currently behind schedule.
What possible
solutions are there?
Here are some possible solutions below.
1.
Each time a file fails to import into the
BetterOnline system, it generates an error file. If someone reads through the
error files and triages the reason for the error, it will stop the file from
simply falling off the radar. Again, the file would still need to be fixed and
imported correctly, as PPL cannot enter in the information manually even if
they have access to it.
2.
PPL can begin to import authorizations from DDD without
waiting for Molina Medicaid approval, as most providers bill using the service
detail reports without waiting for the Molina Medicaid approval. Although the
PPL system is not currently able to import information from the service detail
reports directly, DDD IT is already working on a way to send all authorization
information to PPL regardless of Medicaid authorization approval. This will not
solve BetterOnline’s importing issues, however.
3.
Customer service representative need to be
better trained to identify and communicate the exact nature of the error delaying
the process. It is more frustrating to not know what is going on, and to be
told several different answers, than it is to know the difficult truth.
Customer service representatives also have access to the error file codes, and
may be able determine why it failed to import. This doesn’t mean they can fix
the error, however.
4.
PPL can abandon the BetterOnline system and
process everything manually. This would be slower for some, but would function
much better than the status quo.
5.
A payment mechanism can be developed into DDD’s
IRecord System, and PPL can use this directly to process/track information. PPL
has complained that IRecord is slow, and their willingness to use it ebbs and
flows. As slow as IRecord can be on occasion, it consistently works well.
Conclusion: There
is no light at the end of tunnel for PPL issues. Yelling at customer service
representatives and PPL administrators such as Kimberly Smith and Mark Altieri
will not help, as they have very limited ability to improve the situation. Instead,
the state and advocacy groups must demand that PPL corporate permanently fix or
change their BetterOnline system, and place more resources into their IT
department, or risk losing funding. If this is not done, there will be no improvement
in the processing or payment of services in New Jersey.
