Maryland’s health claims vendor is ‘not up for the job,’ lawmakers are told

A state Division of Well being contractor whose troubled funds system led to a scathing audit pledged anew on Tuesday to enhance its efficiency.

Monica McNeil, CEO of Optum, an organization that processes behavioral well being and addictions providers claims, acknowledged that its cost system hasn’t all the time functioned correctly. She informed members of a number of Common Meeting committees that the agency, a subsidiary of the well being providers big United Behavioral Well being, is “dedicated to doing higher going ahead.”

Whereas the corporate’s aim is to make immediate, correct funds to the state’s well being care suppliers, she mentioned, “I’m not proud at all the challenges that we now have skilled…”

Optum is in the course of a five-year contract with the Maryland Division of Well being. A prolonged evaluate of Optum’s efficiency, released Friday by the Workplace of Legislative Audits, mentioned the corporate’s funds system wasn’t sufficiently examined previous to launch. Consequently, auditors concluded, greater than $220 million in funds for behavioral well being providers lack correct documentation or haven’t been recovered.

Shortcomings within the Optum system have delayed funds to suppliers, who’ve been experiencing an elevated caseload because the pandemic started. Many suppliers have been pressured to spend lengthy hours working with claims adjustors to right errors, an advocate mentioned.

The system’s lapses have prevented Maryland from tapping roughly $28.8 million in federal reimbursements. The corporate processes nicely over a billion {dollars} in claims annually, a lot of it funded by Medicaid.

Though McNeil and a second prime firm official mentioned that Optum is popping issues round, a prime advocate for well being providers suppliers mentioned funds are continuously late and inaccurate. “In case you’re beneath the impression that Optum’s issues are fastened, I’m right here to inform you they’re not,” mentioned Lori Doyle, public coverage director for the Group Behavioral Well being Affiliation of Maryland.

Doyle mentioned the corporate’s use of handbook processing far exceeds trade requirements and serves “as a work-around to its system’s dysfunction.” She additionally mentioned the corporate’s safety flaws put sufferers’ private data in danger.

“The state picked the mistaken vendor, a vendor who was not up for the job,” Doyle mentioned.

There was broad consensus that Optum won’t be renewed when their contract ends in two years. Steve Schuh, a Division of Well being deputy secretary, informed lawmakers that the company intends to launch a brand new procurement by the top of December, to permit for the collection of a brand new vendor and for testing of their well being claims system.

Within the meantime, “they continue to be our contractor,” he mentioned. “(The Optum) system is useful, however we do have to make vital enhancements over the following yr.”

Remarkably, McNeil, the Optum CEO, appeared to concede that her firm can be given the boot in 24 months. She famous that her agency’s contract with the state contains “necessities round transition… to a brand new vendor.”

Lawmakers pressed well being division officers about their oversight of the Optum contract and their failure, thus far, to extract concessions from the agency.

Del. Shane Pendergrass (D-Howard), the chair emeritus of the Home Well being and Authorities Operations Committee, advised that it seems that refund provisions had been both not included or aren’t being enforced.

“I don’t get that you just’re taking duty for the mess that that is,” she mentioned. “How a lot did this price the state of Maryland?” She additionally sought the whereabouts of Well being Secretary Dennis Schrader, who didn’t attend the listening to.

“There needs to be one thing within the contract that claims that in case you’re liable, you’re negligent, and also you price cash to the state, that the state can go forward and attempt to recoup that cash,” mentioned Well being and Authorities Operations Chair Joseline A. Peña-Melnyk (D-Prince George’s). “We have to be made complete. These are taxpayers’ monies.”

Different lawmakers expressed astonishment that Optum didn’t understand that it’s certain by the phrases of the state’s “immediate funds” legislation.

Ye mentioned the company is “imposing monetary penalties” in opposition to Optum, however he didn’t reveal the greenback quantity. He mentioned the company would seek the advice of with its attorneys and reply to the committees’ questions in writing.