Collaborating closely with clients, the OHA, and other trading partners, Quadax established communication for timely updates on the ODM issue.
On February 1, 2023, Ohio Department of Medicaid (ODM) implemented the Next Generation managed care plans, the new Electronic Data Interchange, and Fiscal Intermediary. The goal of these changes, according to the ODM was to provide Ohio Medicaid managed care members enhanced healthcare services that best fit their individual healthcare needs and improve the provider experience by increasing transparency and visibility of care and services.
Current State:
Following the launch in February, Quadax EDI Division began contacting ODM about issues with missing Fee for Service 835s related to the new program.
On July 7, ODM sent out a statement that they were aware of issues affecting the provider community’s ability to consistently receive fee-for-service (FFS) 835 files since the Fiscal Intermediary (FI) launch in February.
ODM confirmed this is an internal issue and that they are actively working to resolve it, and all missing 835s will be delivered as soon as possible.
Also on July 7, Quadax participated in a workgroup with two other trading partners, as well as Deloitte and Gainwell Technologies, to discuss the Next Generation Managed Care program with the ODM. Quadax shared information and addressed various issues on behalf of its clients. ODM reported that there is a problem with the financial system's failure to report the diagnostic-related group (DRG) information pertaining to claim adjudication. It is not due to a previously reported DRG problem with inbound claims, and providers are not required to submit DRG information.
Quadax provided a meeting summary to its clients, and Quyen Weaver, the Director of Health Economics & Policy at Ohio Hospitals, forwarded the same message to a wide audience of Ohio healthcare and hospital leaders.
Quadax Meeting Notes with Ohio Department of Medicaid
- ODM 835s for the week of 07/03/23 were delayed due to the State’s fiscal year end as well as some system performance issues. ODM stated the 835s would be created the night of 07/06/23 with the close of business hours.
- ODM has identified that the previously found issues with the 835/DRG “compliance failures” are related to several defects. ODM attempted a work-around and reproduced 835s, but they were still flagged as a “compliance failure”, which did not allow the 835s to be delivered. A fix has been identified, but no timeline was given as to when it will be implemented. Once this fix is put in place, it will then take several days for the system to catch up and re-process all previously erred 835s. Additionally, a flaw in the 835-creation logic was discovered in the core routines for 835 generation, resulting in the delays. ODM and Gainwell were asked to provide check #s by provider, identifying which have the “compliance failures”. Gainwell committed to provide a spreadsheet to ODM, which ODM will review and internally determine if/how this data can be delivered.
- Another 835-processing issue at ODM/Gainwell was identified and reported to OHA along with the trading partners on the call. A fix for this issue is intended to go 07/07/23 and is related to the release of 835s tied to ‘claim bundling and unbundling’ issues. This is not related to previously identified problems associated with the DRG “compliance failures”. The issue is resolved for 835s going forward. Quadax has asked that ODM send out a notice explaining the issue, so all trading partners and providers are aware.
- Claims are being reported by providers as not reaching the Provider Managed Care Entity (MCE) Payers. This has resulted in roughly a 33% increase in MCE accounts receivable for OHA member hospitals since the transition to the “One Front Door”. ODM is aware and starting to gather the information necessary to determine and resolve the problem.
- In addition to the issues identified above, Quadax reported that individuals at ODM mentioned that the ODM/FI Help Desk can only see files sent to Deloitte but cannot see if Deloitte sent them to the trading partners. This is leading to confusion and sometimes misinformation from ODM, when providers and clearinghouses are calling to report missing 835 files. ODM has informed Quadax that they will be investigating internally, as their various departments should be reaching out to each other when researching and resolving issues.
Quyen Weaver, Director of Health Economics & Policy at the Ohio Hospitals Association, has reported that the ODM has re-escalated the issue related to the Provider Network Management (PNM) module's inability to display claims submitted through EDI. ODM has acknowledged the problem as a high priority but has not provided a timeline for the implementation of a solution.
Next Steps:
Quadax will closely monitor this matter and actively engage in any meetings and workgroups to assist our clients and encourage the ODM to expedite the implementation of the PNM module functionality. Meanwhile, Quadax is collaborating with clients, partnering with the OHA and other trading partners, and will continue to maintain regular communication to provide timely updates on any new advancements.
If you would like to communicate the effects of this limitation on your organization and operations (such as administrative burden and inability to resubmit denied claims) to the Ohio Hospitals Association's Director of Health Economics & Policy, Quyen Weaver, please email her at Quyen.Weaver@ohiohospitals.org. She is collecting this information to urge the ODM to expedite the implementation of this functionality.
Resource link: https://managedcare.medicaid.ohio.gov/managed-care/centralized-credentialing
