Computer glitches, ‘human errors’ causing some eligible Kansans to be denied coverage
by Andy Marso, KHI News Service
State officials continue to whittle away at a backlog of Medicaid applications that developed over the past year.
But as they do so, people with expertise in Medicaid eligibility say they’re seeing an increase in incorrect denials.
The backlog began a year ago when the state moved to a new computer system for determining Medicaid eligibility. The Kansas Eligibility Enforcement System, or KEES, had been long delayed as state workers and a private contractor, Accenture, tried to work out bugs.
Problems remained when the program went live in July 2015. Then, in January, the state moved responsibility for application processing to the Kansas Department of Health and Environment, including some previously processed by the Kansas Department for Children and Families.
That created a bottleneck just as the annual Affordable Care Act open enrollment period funneled thousands of potential applicants to Medicaid, which in Kansas is a privatized managed care program called KanCare.
The result: At one point in February, more than 18,000 new KanCare applications awaited processing, including about 7,750 past the 45-day federal limit. Another 18,000 annual reviews for existing KanCare clients were in the queue, and more than 10,000 of those had been pending 45 days or more.
By that point the state had taken steps to address the backlog, and the federal Centers for Medicare and Medicaid Services requested twice-monthly updates on progress.
KDHE took on extra workers and shifted some existing employees to help with processing. DCF employees who specialized in applications for the elderly and disabled were called to help at the KanCare Clearinghouse — a processing center overseen by KDHE and partially staffed by a private contractor.
The state also set up an appeals process for nursing homes to seek partial reimbursement for residents waiting months for KanCare coverage. The backlog hit nursing homes particularly hard as they provided thousands — and in some cases millions — of dollars in uncompensated care while waiting for residents to gain Medicaid approval.
KDHE officials have focused resources on the new applications and decreed that no one awaiting an annual review would lose their coverage while the backlog persists.
The number of unprocessed reviews ballooned to almost 30,000 by May 8. But by then the number of new pending applications was down to 3,480, with 2,081 of them out 45 days or more.
“We have been working very hard on getting the situation stabilized, and we have made progress,” said Angela de Rocha, a state agency spokeswoman.
Incorrect denials
It’s not just the older applications pending more than 45 days that have been reduced. The state also has been clearing new applications more quickly. The number pending for 15 days or less dropped from 3,000 in mid-March to about 600 by May 8.
Two Kansans with experience navigating the Medicaid eligibility system said that in the state’s rush to make an eligibility determination, errors are popping up that concern them.
Molly Wood, a Lawrence attorney who specializes in elder law, outlined three active cases in which she says clients’ applications were mistakenly denied, plus another two that were approved but with an incorrect patient liability amount for services rendered.
Wood said the three cases had denials for failure to:
• Provide information that actually was provided.
• Produce a 20-year-old assets document that was overturned by the Office of Administrative Hearings.
• Provide more life insurance information within 45 days of the original application, when the request for further information arrived more than 45 days after the application.
“I honestly don’t know how anyone penetrates the KanCare system,” said Wood, who has 25 years of experience in elder law.
Regina Falcetto, an Emporia resident, worked for DCF from 1979 until 2012, when it was known as the Department for Social and Rehabilitation Services. She helped Kansans in the Emporia area apply for a range of assistance programs, including Medicaid, and supervised training of new workers.
In the last few months she has been helping her mother enroll her father in Medicaid. They encountered the same problems Wood described.
Falcetto said after they applied through the online KEES portal, the application was denied. They were told it was because certain documents were missing, but she said she could go back into the online portal and see that the documents had been submitted with the application.
So Falcetto called the Clearinghouse and, after waiting on hold for almost an hour, reached a worker who acknowledged the application had not been processed correctly. The worker told her not to appeal because one of her colleagues at the Clearinghouse was taking a second look at it.
But Falcetto said she appealed anyway because she knew that if there wasn’t an appeal on file, her father might not get backdated coverage for services provided while the application was pending.
She worries that other Kansans who are less experienced with the Medicaid system would not know to do that, or even how to handle the initial denial.
“I can stick on this and I can stick with an appeal, and I’m going to get it done,” Falcetto said. “But what are other people doing? … How many of them are just being denied and saying, ‘OK, I guess I have to do something else?’”
Rachel Monger, director of government affairs for LeadingAge Kansas, said residents of the nursing homes that her group represents report similar problems.
“More families are receiving denials as their applications are being processed,” Monger said via email. “The denials will commonly stem from a lack of documentation. Documentation the family member has sent in three different times.”
State works on remaining problems
Like Wood, Monger said she’s hearing of “wildly inaccurate” patient liability determinations. She said her organization has spoken with KDHE’s deputy director of Medicaid, Christiane Swartz, about the problems, but it’s unclear whether they stem from computer system errors or mistakes by state workers who lack sufficient training.
Falcetto said she’s heard from former co-workers that the KEES system was “not ready,” but she believes a lack of training and experience also is a factor, given the complexity of the Medicaid system.
“They’re hiring people who are unclassified at a lower rate of pay, and they are the ones doing this work,” Falcetto said. “They have very few actual (experienced) eligibility workers.”
De Rocha said sometimes KanCare applicants don’t supply the right documents, but she said some of the problems that Wood and others described can be attributed to KEES while others are “human errors.”
“We are well aware that there are still problems with the eligibility determination process,” de Rocha said. “And we deeply regret the frustration and delay some consumers are experiencing.”
De Rocha said the state is working to make the application process easier by expanding access to paper applications at Aging and Disability Resource Centers, local health departments and DCF service centers after hearing complaints about difficulties for Kansans without internet access.
She said application rates tend to fluctuate from month to month, and eligibility denial rates are difficult to compare because the ACA requires everyone who wants to purchase insurance through the online marketplace to first get a Medicaid denial letter.
De Rocha provided information showing that total Medicaid enrollment in Kansas grew to 434,000 by the end of April, exceeding the pre-KEES monthly averages. It had dipped to about 403,000 at the height of the backlog.
The state projected about $10 million in budget savings due to lagging Medicaid enrollment during that time.
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