Category Archives: Medicare/Medicaid Crossover Issues

DHHS Takes 35 Years to Become Federally Compliant With Medicare/Medicaid Crossover Issues

It is without question that the implementation of NCTracks has been a complete debacle.  NCTracks is the new computer system that is processing Medicaid claims for all health care providers who accept Medicaid in North Carolina.  NCTracks went live July 1, 2013.

Immediately upon going “live,” providers received error messages.  Providers were not timely paid.  If the provider was paid, the reimbursement amount was incorrect.  Depending on the type  of provider you are, your issues varied from other types of providers.  But all types of providers encountered adverse issues.

I still do not understand, even today, why the current administration did not stand up (figuratively and publicly) against Computer Sciences Corporation (CSC) the company contracted to create NCTracks and say, “North Carolina, CSC has created this debacle.  We didn’t hire CSC.  The past administration did.  We will try to fix this debacle now…” That would have been the best public relations move, in my mind.  However, instead, the Department of Health and Human Services (DHHS) stood by CSC and stated publicly how wonderful NCTracks was doing….”NCTracks is on track!”

Oh, well, suum cuique.  Or…to each his own.

One of the biggest problems for providers with NCTracks is the Medicare/Medicaid crossover issue.

What is the Medicare/Medicaid crossover issue?

DHHS explains the crossover issue in the November 2013 Medicaid Bulletin as the “Medicaid Allowable minus Medicare Paid Amount equals the Net Medicaid Allowable. Next, the Net Medicaid Allowable is compared to the Medicare Coinsurance Amount and the lesser of the two is the amount payable by Medicaid.”

DMA also offers the following chart as clarification

   Example No. 1  Example No. 2
Total Billed Charges



Medicare Allowed Amount



Medicare Paid Amount



Medicare Contractual Adjustment



Medicare Coinsurance Amount



Medicaid Allowable



Medicare Paid Amount



Net Medicaid Allowable



Lesser of Medicare Coinsurance and Net Medicaid Allowable Amount



DHHS goes on to say that even though the crossover claims should have been paid according to the above logic, the payments to providers for crossover claims on the NCTracks system versus the HP system may be different, as in, you may be getting paid less on the NCTracks system.

Why? We had the HP system for 35 years.

Well, according to DHHS, because the HP system “lacked the capability to perform such calculations on a claim specific basis. Instead, the prior Medicaid claims system included a “work around” that estimated the amount payable. In some cases, the “work around” paid more than the amount payable in accordance with State law and the North Carolina State Plan approved by CMS.”

Hold on….Hit the brakes!!!

Is DHHS telling us that NC was not federally compliant with Medicare/Medicaid crossover claims for 35 years???!!!!???

So, how much does NC owe to the federal government for overpaid crossover claims over a 35-year period?? And will it be extrapolated?  Maybe PCG can audit NC.

This boggles my mind. 

Here is the other fact that boggles my mind:

According to DHHS, “on October 7, 2013, NCTracks implemented system logic to more precisely pay Medicare crossover claims in accordance with State law and the North Carolina State Plan approved by the Centers for Medicare and Medicaid Services (CMS) on a claim specific basis. The amount of payment is the difference in the amount paid by Medicare and the Medicaid Allowable amount up to the actual amount of the Medicare coinsurance, deductible or both.”


98 days after NCTracks went live???

Why in the world would this Medicare crossover issue NOT be implemented PRIOR TO going live?  The Medicare crossover issue just doesn’t seem to be a “Eh, whatever…Let’s take a gamble” issue.

So I propose a toast to DHHS.  Well done.  Well done on becoming federally compliant as to the Medicare/Medicaid crossover claims (if, in fact ,we are) 35 years later.  And well done, to implementing a NCTracks implemented system to “more precisely pay Medicare crossover issues” 98 days after NCTracks went live.

To timeliness!  Here!  Here!! (the clinking of glasses).

Maybe…just maybe….in 200+ years, NC may fix the broken Medicaid system…