The State of Wisconsin Health Claims process for dual eligible individuals is not working. The State of Wisconsin administers health programs through the Department of Health Services who contract with a 3rd party billing insurance organization who contracts with the service vendors.
The biggest problem is when Medicaid beneficiaries qualify for the Medicare programming as well. When an individual qualifies for both Medicaid and Medicare programming they are referred to as dual eligible.
The State of Wisconsin is consistently struggling to find service vendors willing to contract with the State to serve these aggregates- groups of individuals. This is essentially due to the high cost of getting reimbursed.
In a recent comprehensive audit triggered due to the excessive number of unpaid claims the Wisconsin Department of Health Services identified about 37 thousand claims stuck in process. These were unpaid claims submitted by local pharmacies contracted with the Department of Health Services through the 3rd party billing insurance organization Health Management Systems.
When a beneficiary is dual eligible Medicare is the primary pay source for prescriptions filled through contracting pharmacy vendor service providers. The Wisconsin pharmacies submitted their claims through Health Management Services who through software communication reimbursed the pharmacy and billed the Medicaid fund.
The Medicaid fund denied the claim reaching back in to the Health Management Systems reimbursement process taking money from each individual pharmacy account available as a contract requirement . The pharmacy claims were to be reimbursed through Medicare part D rather than the Medicaid fund.
The contracted pharmacy vendors are now without payment for the service and product they performed as required. The Wisconsin Department of Health Services is now frantically working with the funding source (Medicare), the 3rd party billing insurance organization (Health Management Systems), and the contracted Pharmacies to fix this huge malfunction and prevent the loss of participating service vendors. The sheer number of unpaid claims - 37 thousand sends chills up the spines of budgetary committee members across the State.
Analysts report this study runs from October 2013 to February 2017 and leaves us wondering how many other disciplines contracted to perform a service for these populations are being left without their due payment. This is a part of the recent initiative across Wisconsin to try to retain and gain more service providers for these types of State run programs.
The cost of attaining reimbursement is far outside of the actual rate being paid to the participating service providers. Meaning the program as operating will not sustain and continue to serve the high needs of a growing population.
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