Many states struggle to deploy a new Medicaid Management Information System and Maine is no stranger to those issues.
The state’s prior MMIS implementation was an initial failure – a worst nightmare realized. The State was unable to process claims for six months and issued $575 million dollars in interim estimated payments to providers. After a major remediation release failed in 2006, it was evident that the system would never be federally certifiable and a decision was made to replace it. Maine would need to start over. How could this be done differently to ensure the desired outcome?
Today is a new day – Maine procured a replacement MMIS in 2007 with a new vendor in place by early 2008. The system began processing claims in September 2010 and paid claims from the first payment cycle. What changed? Maine learned several lessons and with a new management team, modified its approach to achieve a successful system implementation. Here’s how we did it.
Competent project management team
Of all the many critical elements included in the recipe for a successful system implementation, the most fundamental is a strong, competent Project Management Team, both at the State and at the MMIS Vendor. The State recognized, based on its recent past, that it needed industry experience and secured consultants with MMIS Project Management expertise to augment the State Management Team. They were secured and in place to help with the procurement process. As the project initiated with the vendor, the state requested a replacement of the Project Manager, when it was evident that the manager initially assigned wasn’t a good match for the role. Soon into the project, the State also changed its Project Manager. Robin Chacón, MaineCare Services Operations Director was a Business Sponsor of the project through procurement, and moved into the role of Project Manager within the first six months of project initiation, as a result of her ability to bridge business process needs with the capabilities of the technical solution.
Strong governance structure
The project to replace the current MMIS was of critical importance; to ensure success it needed a strong governance structure. Leadership commitment to the project was present from the beginning – from Governor John E. Baldacci to Department of Health and Human Services (DHHS) Commissioner Brenda Harvey. The Steering Committee, chaired by Commissioner Harvey, was comprised of several key state and department leaders – the State CIO, Medicaid Director, Deputy Commissioner of Finance, and Deputy Commissioner of Benefits and Operations. The group met weekly throughout the 30-month project and received project updates from the State Project Manager, concerning both what was working and what wasn’t. The Committee provided guidance to Chacón and took action when needed to overcome obstacles and keep the project on course. Chacón also chaired a Governance Team, comprised of senior management from various DHHS Offices dependent on the new system, to exchange information and solve issues.
Dedicated project resources
Although scarcity of State resources is a common challenge across the country, Maine learned from its past mistakes that a dedicated project team was critical to the success of a project as large and complex as an MMIS implementation. The State committed subject matter experts from Medicaid Operations and Policy, State Information Technology, and augmented state resources with consultants that had expertise and prior experience in MMIS implementation.
Partnering with CMS
As much as it meant to Maine, it was just as important to CMS that this project succeeded. From procurement of a vendor, CMS was engaged as a partner. CMS regional leadership joined the Steering Committee at least once a month, more frequently as the go-live date drew near. CMS was also an excellent resource for guidance during design and development to navigate obstacles and solve problems encountered.
“Being part of the monthly steering committee allowed CMS to provide real-time assistance to the state and in turn move the project along in a more expedited manner,” said Richard McGreal, CMS assistant regional administrator.
When design decisions needed to be made, Chacón often used CMS as a resource to understand what impacts a course of action would have on certification or to identify contacts in other states that may have encountered similar issues.
Accountable project management
Holding the vendor accountable to the contract is crucial. It is important to emphasize that the vendor is the technical expert for their product and responsible for bringing the right resources, both subject matter experts and volume, to the project to implement the system within the project schedule. When a vendor is not performing to the standard needed to keep the project on schedule, or at the quality level expected, performance letters are a way to correct behavior. It is important that these are timely, identify the deficiency, and define actions expected to cure the situation.
Just as important as holding the vendor accountable, the State team needed to meet its deadlines and deliver information in the timeframes requested by the vendor. It would be difficult if not nearly impossible for the State to hold the vendor accountable, without first being accountable themselves. When an organization has competing objectives and scarce resources, senior management direction helps to get things done. This is where strong leadership and executive management support was critical.
Eye on the prize: Tracking certification from day one
The most important goal of implementing an MMIS is to achieve CMS Certification of the system. This increases the Federal Financial Participation (FFP) of the operation of the system from 50% to 75%. This funding is critical for state budgets – Maine has been operating with 50% funding since the implementation of the prior system in 2005 that never achieved certification. In 2007, CMS released a new Certification Checklist as guidance for states to better manage MMIS projects. Maine used this checklist from the beginning of the project to track requirements through design, development, and testing to ensure the system would be certifiable once implemented. Maine had already completed procurement when the list was published, but we would recommend that these be included in the Request for Proposal for new MMIS procurements.
Engaging providers: Communication strategies
Providers play an important role in serving the Medicaid population. They are directly impacted by the implementation of a new system. Maine used the implementation of the new system to modernize the MaineCare program and had over 120 policy changes as a result. Changes included the elimination of local (proprietary) procedure codes, simplification of policies, and standardization of reimbursement rates and billing practices. This required providers to modify how they billed claims. It was important to communicate with providers early in the project and consult with them on recommended changes. This was achieved through several venues:
• Provider Advisory and Technical Advisory Groups – Comprised of various associations such as the Maine Hospital Association and the Maine Medical Association, and individual providers. These meetings were held monthly and engaged providers in reviewing policy changes, design solutions, and provider communications.
• Provider Forums – Open to any provider, attendees could join the forums in person or via the Internet through a web-meeting to communicate project status, information, and high-level training – what providers could expect with the new system. This began 10 months after the project commencement and continued through system stabilization post go-live.
• Provider Pilot Testing – Providers representing all provider types were engaged in the testing of the system including provider enrollment, prior authorization, and claims processing. They had the opportunity to submit claims and receive a sample payment remittance to simulate the complete processing cycle of claims. This helped the State by identifying additional errors prior to implementation.
Test, test, then test some more
A strong testing strategy is the cornerstone of any project, but all too often gets sacrificed as project delays creep in during design and development phases. The testing approach was modified to take an iterative approach, to test functionality as it was developed, with regression testing included in each testing step. In the final test stages, both claims volume testing and provider pilot testing were performed to capture production-like scenarios.
Although an iterative testing approach can be risky if not closely managed, what is most important is to not eliminate testing or shrink the scope of testing. To ensure testing would not be compromised, measureable Quality Metrics were established at the beginning of User Acceptance Testing. This set a benchmark to ensure that quality standards were achieved to support the Go-Live decision to implement the system. This was done early as often decisions are pressured by the project timeline; when that happens quality is compromised.
Maine actually delayed the implementation several times as a result of the Go-Live Criteria not being achieved. It is a difficult message to deliver – to CMS, to the Governor and Legislature, and to the community, but when the foundation is quality-driven it is the right message. We toiled over delivering the difficult message, and were always relieved to know it was the RIGHT decision backed up by testing evidence! It is much easier to correct and retest before implementation, than to correct in production.
Even with rigid Go-Live Criteria, an MMIS is so complex States have to assume there will be deficiencies that need to be addressed in production. Maine completed contingency planning for several scenarios including:
• Individual Provider issue – an issue affecting an isolated provider
• Provider Type issue – an issue affecting providers of one type (i.e. physical therapists)
• All Providers issue – an issue affecting all providers, such as a batch payment processing issue
This contingency planning was developed by the State and MMIS vendor, and escalated through Project Governance and with CMS to confirm processes were documented and in place should an event occur that required quick response.
Based on the deficiencies in the current MMIS, the State of Maine took a unique approach to the design, development and implementation of the replacement system. A Date of Service (DOS) cutover strategy, although common practice in the commercial payer industry, has not been an approach supported by CMS in State Medicaid system implementations. Date of Service cutover method requires the new system to only process claims beginning with services administered on a specified date of service. Using the traditional Medicaid approach of Full System cutover would require Maine to support claims paid in the legacy MMIS, and recreate processes that were deficient. Understanding the challenges Maine faced, CMS authorized this method, knowing the risks of recreating the past could be much more costly in the long run. The benefits of this approach proved to be:
• Controlled design scope – The legacy MMIS was not compliant with the requirements of Health Insurance Portability and Accountability Act (HIPAA) and the new system was required to achieve compliance. The approach allowed the State to focus on implementing standard billing practices and compliant processes during design and development.
• Contingency Planning – Because this approach included a run-out of claims in the legacy MMIS, there was a contingency option to convert back to the prior system if the new system experienced a fatal failure at go-live.
• Ramp up of claims volume – Because the replacement MMIS processed claims for a specific date of service forward, there was a gradual ramp up of claims volume, so quality control staff could review claims as they came in and correct deficiencies before many claims were impacted.
The DOS implementation approach also allowed the state to deploy system functionality in Phases. The first phase, although not related to DOS was also a lesson learned from the prior project, the state required all Providers to re-enroll as Medicaid Providers. This functionality was implemented one year prior to full Go-Live, and minimized conversion issues with critical provider information, required to ensure Providers could be paid in the new system. Next, the Electronic Data Interchange (EDI) Gateway was implemented nine months prior to go-live and allowed providers, billing agents, and clearing houses to test HIPAA transactions to ensure their systems could communicate with the state. Prior Authorization functionality was implemented one month in advance of the full claims Go-Live, to ensure services were authorized for DOS claims that would be billed in the new system. This phased approach allowed the project team to remediate defects of various components in stages with focused resources.
Post-Go-live: System stabilization
Even with all of the actions mentioned above, it would be incorrect to assume that no issues would be experienced at system implementation. Most critical to stabilization was the continuation of a strong governance structure, rigid change management controls, testing of remediation functionality, and continued communication with providers. Following the implementation of Prior Authorization and Claims Processing functionality, Provider Forums were moved to weekly via conference call and were used as a vehicle to share known issues and corrections. The Provider Portal was also used to communicate this information is a centralized place.
Although the system stabilization continues, as to be expected, we strongly believe that there is no question that the Maine MMIS system will achieve CMS Certification. What is important to note, is that Maine did make mistakes in the past, but has learned from them. We hope that other States can also learn from these lessons as they commence the daunting undertaking of MMIS projects in the future.