CSC Revolutionizes Medicaid Management for New York State

As a result of the first phase of the eMedNY implementation, the state of New York now has the ability to verify Medicaid eligibility, issue service authorizations and process prescription claims online and in real time. With the completion of the project’s second phase, in 2005, the present Medicaid claims system (also operated by CSC) will be completely replaced with a real-time processing environment for all claims, including institutional, professional and dental.

To Rick Kelly, senior partner of CSC’s consulting systems integration group, the system marks a significant change in Medicaid management. In what Kelly calls the old world, providers submitted claims in batch form via electronic tape, computer linkages or even paper forms, but they would have to wait about two weeks to find out if the claim was approved for payment. The new world will move much faster, says Kelly, with the submission of claims and approval status both occurring in real time.

Getting there is complex because it involves the integration of many functions. eMedNY, however, will fuse together claims processing, eligibility verification and reporting capabilities required by the federal government. All these previously autonomous systems are being integrated into a HIPAA-compliant eMedNY, in addition to a data warehouse — a platform that offers tremendous potential.

The real benefit for New York is cost savings, which are realized only partially in financial terms. The process of moving from batch to real-time processing gives the state the framework to provide better service and rapid support for changes in state policy, which translates into a greater return on investment. With the capability to image documents and store them in an online image repository, state users will have all the information they need for decision making contained in one system. All of this points to greater workplace efficiency and labor-related savings, which are welcome since most states are experiencing a shrinking employee base and budget challenges. Functionality built into the main system and data warehouse will provide the support for electronic funds transfer to providers and improved tracking for fraud abuse detection.

Building a system that never sleeps

Bill Liddle, vice president of Medicaid programs, says New York views eMedNY partly as a “life or death system, largely due to the volume and importance of the program it supports.” He adds that CSC processes more than 400 million Medicaid claims annually for the state, which amount to more than $33 billion in payments per year for New York.

Consequently, penalties totaling $2,000 per minute for outages were built into CSC’s contract to ensure the system’s 24x7, 365 operation. CSC set to work, building a new data center in Albany and establishing robust policies and procedures surrounding the technical environment, platforms and networks. The goal was to eliminate single points of failure while building processes for disaster recovery and institutionalizing them, so that the processes were understood.

Over the course of a month, CSC ran a production simulation test and practiced recovering from system failures that the team generated. Kelly says his team pumped a million transactions per day through the system and completed daily, weekly and quarterly cycles running all of the system’s functions. In turn, the internal audit team ran totals on claims paid and tracked them against the real system to verify balances.

There has only been one 34-minute outage since the system went live on November 16, 2002, on Christmas Eve of that year. Only a small group of providers was affected during this traditionally slow period for hospitals. Kelly credits a total team effort, as well as intensive planning and practice for CSC’s success.

Breaking new ground in architecture

With such heavy emphasis placed on stability and penalties built into the contract for downtime, CSC went the extra mile to ensure the system would run despite any obstacle. In the process, the team created architecture that is completely unique. “We’re doing things that few people are trying,” says Kelly. “This project involved treading new ground.”

One major concern involved how to keep the system resilient if faced with some sort of catastrophic failure. The solution was to use Hitachi’s disk mirroring technology to replicate data from the operations site to a separate disaster recovery site. As the eMedNY system processes transactions, they are communicated to the data recovery system. In a disaster, CSC would be able to switch to the disaster recovery network and resume processing. Although the switchover is not instantaneous, the system would be back in operation within a day or so — a scenario that would be very difficult to replicate without this type of backup, says Kelly.

CSC will implement full parallel sysplex data sharing as part of the Phase 2 deployment. Kelly says this environment has been accomplished at only a handful of companies globally. A coupling facility links two large mainframe computers that share a common DB2 database between them. This provides the ability to load balance between the mainframes, and continue to process Medicaid transactions should an environmental failure occur on either complex. Maintenance and software work are also easier to manage since one mainframe can operate the business while maintenance or upgrades are performed on the other mainframe.

“CSC has created parallel sysplex environments and data sharing environments, but this is the first time we will merged both in the same environment,” says Liddle. “This is bleeding edge technology.”

Parallel sysplex data sharing seems ideal for transaction-intensive environments and for those operating 24x7, but few companies have integrated this type of architecture. “Many people are aware that it can be done, but the learning curve is significant,” says Kelly. “The processes and procedures are more critical than the technology. If something goes wrong and you don’t know what you’re doing, recovery can be incredibly difficult.”

Kelly credits three of CSC’s top engineers and architects with leading the team through the challenging architectural aspects of the project. Mike Dyer, Robert Barringer and Andy Galat, known globally for their innovative work, acted as thought leaders on the project.

The Data Warehouse – Enabling great functionality

The state of New York supports more than 60,000 healthcare providers, but before the implementation of the data warehouse into eMedNY, the government had no effective means to track provider services or prescription patterns. Now the state has access to five years worth of data that will enable the agency to make more informed decisions regarding policy.

CSC executed an exhaustive data validation process to ensure the accuracy of New York’s Medicaid information stored in the data warehouse. The effort resulted in a repository of data that is becoming the exclusive source of New York Medicaid data for the majority of state-operated data marts.

“Medicaid is a huge program,” says Liddle. “The information captured in the data warehouse is effective for a scientific sampling device.”

With the ability to extract and analyze data being processed as claims come in, as well as serving as a storage unit for patient, provider and financial information, the data warehouse can be used as a tool to detect potential epidemics. “It would be possible to track pharmacy claims by region and assess patterns in provider services to get a big picture,” says Liddle. “If the state was ever faced with such a situation, the system would help them piece the puzzle together fairly quickly.”

Liddle says that other states are moving in the direction of implementing data warehouses because they offer so much potential, including the ability to incorporate information from all 50 states.

Stephen Kalish, president of CSC’s civil enterprise integration division, believes that they have everything to gain. Not only has processing time for New York’s claims improved with the installation of eMedNY, but maintenance costs have fallen, overall accuracy has increased and the state will soon achieve HIPAA compliance. “This is a modern system that can manage the volume of today’s Medicaid program. Essentially it embodies a new level of excellence.”

Kalish says that the creation of eMedNY speaks to the caliber and character of CSC people and their focus on client relationships. “Projects like this one are bound to be difficult because no one has ever built a system like this before,” says Kalish. “But CSC is a company made up of experts and innovators that are very customer-obsessed. When our client of more than 10 years calls and says that they need an improved Medicaid system, then we will break new ground and deliver exactly what they need.”

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