Lawsuit will shine light on Medicaid claims

By Scott Mooneyham | Jan 20, 2014

RALEIGH — Over the past year, one of the more difficult stories that newspaper and television reporters have followed is the state's changeover in its Medicaid software claims system.

The media coverage has more than established that the new system, called NCTracks, has been extremely troubled.

Since a July 1 launch, medical practices and hospitals have failed to receive payments for a variety of initial claims because of glitches in the system.

The state health officials who oversee the Medicaid program and the new system, including department secretary Aldona Wos, have admitted that the system, at its launch, had more than a few defects.

What has been difficult for the press to reconcile are claims by Wos and other officials in the Department of Health and Human Services that the system is getting better against vague and whispered portrayals from others that they are not.

Even as state legislators began delving into the issue last fall, McCrory administration officials sought to put some of the blame on the medical providers themselves, attributing a lot of problems to medical administrators entering improper codes.

Then Wos and her deputies began talking about how many claims the system was processing, as opposed to those not being processed.

A month ago, in response to another critical state audit, Wos wrote: "Although NCTracks has fewer defects per function point than industry average for a comparable software system, we understand that some providers have not received payment for their claims for services. We have and will continue to work diligently to ensure that every provider is paid timely and accurately for covered services rendered."

While a few medical administrators have spoken up during legislative hearings, most have allowed the public criticism to come from politicians and auditors.

When you depend on people for money, shouting and fussing about those same people can be a dangerous exercise.

That all changed with the filing of a lawsuit, led by seven medical practices, against the state and the contractors who were hired to put the Medicaid claims system together.

The lawsuit includes some very specific claims indicating that NCTracks may not be getting any better.

One example involves patient co-payments and how the system shorted doctors $2 by applying the wrong co-payment amounts. The problem appeared to be fixed at one point, but the lawsuits says one of the plaintiffs discovered it recurring as late as December.

The medical practices also cite continuing problems when it comes to being paid for ultrasounds, vaccines and services that require patient consent forms. Even in cases where specific types of claims are now being paid, the medical practices have not always been paid for services when payment was previously denied, the lawsuit said.

It is far from certain what this lawsuit does when it comes to making whole individual medical providers.

What it may do, though, is show whether North Carolina and its taxpayers have bought a lemon that can never really be fixed, or something that just needs more tuning up.