Imagine two health care providers.

Provider “Anthony Loves” is a home health agency with approximately 15-20 staff and Medicaid accounts for 100% of its business.  Provider “Huma Health” is a large corporation at which 10 medical professionals provide primary care to pediatric patients.  Medicaid constitutes 20% of Huma’s payments; private insurance companies make-up 80% of the income. Which provider, Anthony Loves or Huma Health, will be most adversely affected if NCTracks suffers a “glitch” and Medicaid reimbursements are not paid timely? Answer? Anthony Loves. In fact, most providers similar to Anthony Loves have approximately 2 pay periods, or, maybe even 1, that can pass without Medicaid reimbursements before the providers are forced to close their doors.

Discrimination against small providers? Probably not. Disparate impact? Maybe. Just plain, old unfair? Absolutely.

Since July 1, 2013, when NCTracks went live, the Department of Health and Human Services (DHHS) has touted the beauty, the efficiency, and the overall success of NCTracks in  the media. DHHS is sugar-coating a state-wide, disastrous pill for small providers to swallow.

Is NCTracks successful in a discriminatory manner?…As in, are small providers suffering the errors of NCTracks disproportionately than large providers, i.e., hospitals, large institutions. Will NCTracks force small providers to close?

Is the NCTracks’ Medicaid reimbursement system resulting in a “disparate impact” on small providers?

I know, I know, I know…”disparate impact” is used in constitution law when describing a discriminatory situation in which a minority group or protected class is adversely affected. And…I understand that a legal “disparate impact” argument does not apply to small providers, as, unlike women or minorities, “small providers” do not constitute a “suspect class.”  And I understand that NCTracks is not a “law” per se (normally in a case for “disparate impact,” you have to show that a statute or law is causing the “disparate impact”).  So, folks, please understand that I am using “disparate impact” loosely for the purposes of this blog and not according to the legal definition of “disparate impact.” (Professor Kobach would be disappointed).

Example of REAL “disparate impact”:

Back in 1974, New Bedford had a law that stated that a person applying to become a police officer must be 5 feet 6 inches or taller.  Obviously, the 5’6″ requirement disproportionately adversely affected women because, generally, women tend to be shorter than men. Obviously, I would never have been able to be a police officer in New Bedford in 1974, as I am 5’4″.

In a landmark decision, Costa v. Markey, the Supreme Court stated that the law (requiring police officers to be 5’6″ or taller) was not discriminatory “on its face,” but, rather, the impact of the law adversely affected a suspect class (women), thereby rendering the law unconstitutional due to the “disparate impact.”

Similarly (and not so similarly), NCTracks, “on its face” appears to be non-discriminatory.  All Medicaid providers who render Medicaid services submit claims for reimbursements through NCTracks and will get paid. Period. No discrimination. But, what if, the reimbursements paid out from NCTracks are paid-out to large providers in a disproportionate amount as compared to small providers? What if small providers are suffering a “disparate impact?”

So far, when asked about any potential glitches with NCTracks (and by glitches, I mean, providers are not receiving Medicaid reimbursements), DHHS says, “Sure, there are glitches; sure there are bumps; we expected bumps.  But, overall, NCTracks is the bomb-diggity.” (DHHS does not use the term “bomb-diggity,” but you get the point). Again, sugar-coating.

According to DHHS, NCTracks has processed nearly 9.3 million claims in the last checkwrite, and as of the last checkwrite, the system has been on or ahead of schedule with checkwrite payments, paying out more than $350 million to health care professionals.  That’s a lot of payouts. If DHHS is correct and NCTracks has paid out over $350 million in Medicaid reimbursements, then why have I been receiving so many phone calls and emails from Medicaid providers who have received ZERO Medicaid reimbursements since June 20, 2013? Which leads me to question…of those 9.5 million claims, were those just the successful claims? How many total claims have been attempted in all?

When asked for the breakdown of Medicaid reimbursements actually paid, DHHS sent:

The pharmacies are getting paid.  But what services are included in “Medical?” Everything else? What is the breakdown of “medical” payments? Does “medical” include hospitals, dentists, primary care physicians and every single medical services?

I do not know what medical services are bunched together to constitute the $351,367,812.52 medical payout. But from comments I have received regarding lack of Medicaid reimbursements due to NCTracks, it appears that small providers are suffering. It appears that small providers are suffering a disparate impact.

Below are some comments by NC providers who accept Medicaid and have not been paid by NCTracks:

“Our peds practice is a month with no pay, and we are 85% Medicaid. Noone at NC tracks seems to be able to tell us (despite multiple 60 to 80 hours phone waits) why we haven’t gotten paid and when we will get paid….Because we care for very complex kids (we are a NCQA Level III certified medical home & get frequent referrals from Brenners Childrens Hospital) and have such a high Medicaid population, I haven’t payed myself a salary in 6 years, and my husband and I have put our savings into the practice, but now I can’t pay my employees either.”

“I have not been paid yet either and it is shameful. If this is some nefarious plot to thin out the number of providers I think it is working. We have been on the phone for HOURS and still no resolution. They blame our third party processor and our third party processor blames them. We are stuck in the middle.”

“Small therapy and Infant Toddler(SLP, OT PT, CBRS) providers are being hit hard. Another long work week has come to an end with no hope of reimbursement in sight. We have to continue to serve our families indefinitely or run the risk of losing our entire caseloads, which would cause us to have no choice but to shut the doors. We have been a small, but successful CBRS provider agency for 9 years (ironically, July 1 was our 9 year anniversary), but NC Tracks may just do us in. We are being told it is our EFT info that is keeping us from getting reimbursement. We submitted our EFT info on 5/17 but it did not show up in the NCT system until 7/10. We could not fix or check on anything ourselves because the Status and Management Change option in the Provider Portal was not functioning for us from 7/1 until 7/16! On 7/10, a rep verified and re-submitted the EFT info. It’s 9 days later and still nothing has shown up at our bank. The supervisor I talked to today sounded so proud when he announced, ” I have found out what your problem is! You are still in pre-note because your bank has not responded. I had to explain again that it is a system error on their part. It looks like it has been sent out, but it never shows up at our bank. This is apparently a common problem and there has to be a fix for my agency and quite a few of my colleagues before we all just go under.”

“This is absolutely accurate and correct. This is happening to our 2 practices, one in Charlotte and our new office in Huntersville. This is the deception that Doctor and I as the Office Manager are experiencing. Very sadly to say we have had the run around for the past 3 weeks as of when we will get payments in so we can continue operations and make payroll. Today the owner was faced with withdrawing monies from his 401K to make the payroll for the staff since our practices are 65% Medicaid based. We love our job and servicing the community; however we won’t be able to survive if we don’t receive payment for our services. At this point we have contacted the senators and we areliving our way up to see if we are heard. I am appalled at how we are still awaiting on payments from claims of 06-20-2013, when NCTRACKS was supposed to take over on July 1st. I would like to get Action 9 involved and see what else can be done to expedite these payments to all the providers. If so, why did they even switch the system. What a disappointment.”

“We’re a mental health agency. We should have been paid today for the first time since the 20th but of course we weren’t. No RA posted either, even though we received an RA for last week’s claims. Sad to say but I wasn’t expecting to get paid because I have no faith in DHHS’ ability to implement any program. They are the epitome of governmental incompetence.”

“I am responding to this information from a pediatric dental practice, Coastal Pediatric Dentistry, in New Bern, NC. We are dealing with a nightmare situation with NCTracks so far. Our taxonomy number has defaulted to another number which is not dental so I have been told that the reason all of our claims have denied is because of the wrong taxonomy number. The person that I spoke with at NCTracks said she couldn’t access our provider profile to tell me how to fix the problem. So here we sit with hundreds of Medicaid claims denied. How long can a practice continue like this?”

“I am a dentist in Sanford NC and I have not been paid by Medicaid since June 27. They stopped accepting our claims June 20th.”

“This is an absolute horror story. I cannot find anyone who has any idea how to bill for the dually eligible that require a Medicare override. How to match the list of taxonomy codes which I have never seen before to my one NPI and bill properly for regular Medicaid recipients and CAP waiver supplies. We have not been able to bill anything successfully.”

“Well..I stayed on the phone 57 mins this morning to only be told the complete error description for my denied claim. I asked the help desk rep, can you please step through the process of filing the claim for PCS. I was then given information to the NC DMA site (outdated info – they still have the old HP site info up), upcoming webinars (live so to speak) and so forth. But, I’ve have yet to see any “concrete” examples of claim processes for various group settings. They’ve all been so generic, it’s not helpful at all. I went to a class in Greensboro, NC 2-months ago. The trainer didn’t have specifics, just generalities. I’ve been in IT over 18 yrs, specifically in Application/Development and I knew this rollout was gonna be bad. I’ve called Vendors and they hadn’t figured it out yet. I gave the help desk person this AM some ideas…She actually took notes! That was my highlight of claim processing with NC Tracks today. By the way, 2 days of trying to submit a claim. Unsuccessful! Trial & Error right now!”

Why have these providers been wholly UN-successful when NCTracks has supposedly paid out $350 million since July 1, 2013? Why has DHHS neglected to bring this issue to light?

My guess? Small providers are not receiving Medicaid reimbursements, whereas the big providers are being paid.

If Duke University Medical Center were not receiving Medicaid reimbursements, we would have heard some very loud complaints. Same for Rex and UNC. Since we have NOT heard from hospitals regarding nonpayment of Medicaid reimbursements, I am inclined to believe the hospitals ARE getting reimbursements.  Maybe even $350 million worth.

The providers quoted above are not large institutions. They are small/medium-sized Medicaid providers. Not being paid for 5-7 weeks is devastating for the smaller providers.

Which leads me back to my original question….Is NCTracks creating a “disparate impact” on small providers?

I believe yes.

So what is the solution? A lawsuit?

In the last few days, I have been contacted by numerous dentists, home health care providers, and behavioral health care providers, who have not been reimbursed for services rendered and who would like to sue Computer Sciences Corp. (CSC), the company that created NCTracks.  CSC is being paid $484 million for developing the system and running it through 2020.  The problem with all lawsuits against large entities, such as CSC, is the price tag. A lawsuit is so expensive that it impedes providers from being able to bring a lawsuit. 

Maybe the NC Dental Society should think about pitching in and helping its members…

Or a behavioral health care society….

Or a medical society….

Regardless, providers need to know that other providers are also suffering. And if any provider IS receiving Medicaid reimbursements, please share what, if anything, you did to get NCTracks to work.