Wednesday, June 27, 2018

Consumer Advisory: The Root Cause of the PPL Problem

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.

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