ACTS TESTIFIES at PUBLIC HEARING
IN ALBANY FOR NEEDED E.I. BILLING CHANGES
On October 22, 2013,
the State Assembly held important legislative Hearings in Albany into the problems with the Early Intervention billing transition
and Fiscal Agent. Along with a number of other associations and providers ACTS presented the following testimony which was
very well received by the panel of Legislators. ACTS will be following up with additional meetings and communications with
members of the State Assembly and the State Senate in advance of their return to Session in January. This testimony was delivered
to the Legislature by ACTS Executive Director Steven Sanders, who for 28 years was Member of the State Assembly and
one of the original sponsors of the law creating Early Intervention:
Thank you for this opportunity to address the Assembly
Committees on Health, Insurance and Oversight, regarding the critical issues impacting the Early Intervention Program, which
for 20 years was the envy of the nation.
Early Intervention is estimated to save seven dollars for every dollar that the state invests. This
is true because successful Early Intervention AVOIDS or REDUCES far more expensive Special Education services which
multiplies costs to school districts and to the State significantly. Over 70,000 preschool toddlers need these critical
services each year. They and their families are served by highly skilled and dedicated professionals and agencies.
Yet the Early Intervention
Program has been unnecessarily placed in serious crisis this year.
Because of an ill-conceived transition process in the billing protocol resulting
from a change in the law, for months this year providers were not paid, at all…and now nearly seven months into this
transition, long delays in reimbursements, particularly for commercial insurance claims, persist. According to the DOH’s
figures nearly 60% of commercial insurance “claims” since April STILL remain in limbo. That equates to over 70%
of the actual dollar reimbursements still owed to providers! A case in point: members of my association
on average are still owed 77% of their commercial insurance claims.
The Department of Health would have you believe that things are going fine
now. They most certainly are not. They may tell you that 85% of total claims have been responded to. However taking nearly
seven months to reach that figure is not a measure of success. It is a statistic of futility and one that cannot be continued.
Many providers faced with insolvency resorted to financing costly loans using their homes and personal
assets as collateral just to keep services to at risk children from ceasing.
How did a program that operated so well for two decades devolve so quickly
in just a matter of months?
Fortunately the answer to that question is
NOT complicated… nor are the remedies.
In 2012 Governor Cuomo proposed drastic changes to Early Intervention which would have delegated control
of the program to commercial insurance, creating an odd managed care medical model, totally unsuited for this education readiness
program. The Legislature correctly rejected that idea and instead approved what it thought were some cost saving and streamlining
measures. Effective April of this year providers would contract directly with the State instead of local Counties. A
State Fiscal Agent was supposed to be established to manage all provider claims.
The measure also relieved counties of their time consuming responsibility of
processing billing and recouping payments from third party payors. It was believed that the Fiscal Agent would assume most
of those tasks on behalf of the State.
However no Fiscal Agent was in place when the transition began on April 1. Thus no claims were processed
nor were any payments made for nearly two months.
The massive amount of paper work and interaction with commercial insurance companies previously handled
by County governments, has somehow become almost the total responsibility of unprepared and uncompensated providers. Nobody
expected this! These are early childhood professionals with advance degrees in learning therapy services. They are not hospitals
or medical groups. They are not, and will never be, insurance billing experts. It is foolish to believe that
individual therapists or agencies can succeed in collecting more money from commercial insurance when local governments with
its official powers and resources could not.
And IF there was the thought that the
Fiscal Agent would act as an intermediary between providers and insurance companies, that simply is not happening.
Providers, large and small are incurring hours and hours of additional work each week and tens of thousands of dollars in
additional unreimbursed costs. Once they submit their claims to the Fiscal Agent it becomes largely the responsibility of
providers to deal with the overwhelming tangles and questions from insurance that inevitably follow. THIS
MUST CHANGE. Providers and agencies are not equipped to assume these extensive and time consuming tasks, and certainly not
without any reimbursement.
Moreover just three years ago the Department of Health spent millions of dollars installing a new computer
tracking and billing system for Early Intervention called “NYEIS” (New York Early Intervention System). The detail
and data on claims uploaded by every provider should be sufficient for the Fiscal Agent to submit clean claims without insurance
companies subsequently making ever more demands for additional information.
Before this change in the billing law most providers received payment of virtually 100% of their claims
within about a month of their billing submission to their County government. And at a minimum they knew when to expect payment.
Now, they have no idea how much or even when they can expect payments. THAT TOO MUST CHANGE.
I am quite certain that when the Legislature
approved this new system of billing, most Members thought that the much heralded Fiscal Agent would be interacting with insurance
to assure that providers would be paid within a reasonable time frame. That has NOT turned out to be the case.
It is CRITICAL
to understand that the Fiscal Agent is supposed to pay providers whatever insurance will not. BUT the Fiscal Agent will not
pay providers at all until insurance has decided how much of the claim (if any) they will pay. With commercial insurance in
particular that process has proven to take months and months and months! And consequently providers must wait months and months
and months to be paid for services rendered.
Providers cannot run their programs, pay their obligations, and serve their clients if they cannot
have a reliable expectation of when they will be paid. Such a system is simply untenable and financially unsustainable…
and terribly, terribly unfair. And it is jeopardizing services to your constituents.
Sadly I do not anticipate that this situation will improve
sufficiently without legislative correction.
The Bureau of Early Intervention has tried to ameliorate and resolve problems, and I give them much
credit for their efforts and thank them for their help. It is appreciated. However there is only so much that they can or
are willing to do within the context of the current law.
In order to restore some semblance of order and balance, providers must
have prompt payment of their claims within a reasonable and finite time frame. And their overwhelming new administrative
tasks must be both lessened and reimbursable.
This can be achieved. But in order to do so certain policy changes need to occur:
must be paid if not by commercial insurance or Medicaid then through the escrow account within about 30 days of when that
claim is electronically submitted to insurance. If insurance entities do not adjudicate a claim within that period of time,
then it must be the responsibility of the Fiscal Agent to immediately remit payment to providers and reconcile the accounts
at such later point that insurance does finally adjudicate the claim.
2) Claims from providers that are submitted through NYEIS
should be first reviewed by the Fiscal Agent for completeness through appropriate software filters and then sent to Medicaid
and commercial insurance for adjudication and payment.
Whatever information is required to be provided through NYEIS should be considered sufficient
for insurance adjudication.
and Service Coordinators must be reimbursed for their new administrative tasks and expenses.
5) All remittance, information and
payments should be sent by commercial insurance to the Fiscal Agent. The Fiscal Agent will remit
payment to the providers.
here is another thought suggested by a prominent legislator: Since commercial insurance reimbursement only accounts for about
3% of the total E.I. payments which according to the Department of Health, is not expected to change much in the near future,
why not avoid the billing morass altogether and simply assess a fee on insurance companies on a proportional basis to raise
the equivalent revenue expected from those companies? It would save all parties much time and grief and allow services to
be provided by therapists and agencies unimpeded, and probably more efficiently. There would be no additional cost to State
and local governments; commercial insurance would be responsible for its fair share; and providers could be reimbursed by
the Fiscal Agent promptly. It is a fascinating idea.
But whatever road the Legislature chooses, it must not choose the path of status
quo with the current system unchanged. That is a road pocked with more difficulties for providers and less access to services
for children and their families.
Early Intervention was one of the most successful programs that this State ever created, providing desperately
needed help to learning delayed youngsters and saving government tens of millions of dollars each year in avoided costs. It
needs to be fixed, NOW, and restored as the exemplar that it was for 20 years.
One thing for sure… that one year old or two year old child needing
services cannot wait a year or two. The clock will not stop while government hopes that the system will right itself. It will
not, and wishing won’t make it so. What is required are amendments to the law as soon as the Legislature returns
to Albany. A year in the life of a small child can make all the difference for better or for worse. PLEASE choose