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Medicaid system criticized

Error found in '99 was never resolved, some say

By STACY FORSTER
sforster@journalsentinel.com

Posted: Oct. 23, 2005

Madison - Despite learning years ago that a computer error had potentially denied thousands of eligible residents access to Wisconsin's Medicaid program, state health officials have done little to follow up and be sure those people are covered, advocates for those denied coverage said.

State health officials dispute the idea that many people are lacking coverage to which they are entitled and said the state already does sufficient outreach to be sure those who need help get it.

Still, critics say the state has fallen down on its responsibility to ensure that people improperly rejected were later allowed into the state's Medicaid program for the working poor, elderly and disabled.

"We think there are many thousands of people who were incorrectly denied and had no idea that something went wrong," said Mike Rust, of the health care advocacy group ABC for Rural Health in Balsam Lake. The state should take steps to identify who was denied over the nearly five years there was a problem in determining eligibility and invite those who are eligible to apply again, he said.

"After you assess the extent of the problem, find a way to make it right," Rust said.

The state's Public Health Advisory Committee adopted a resolution last month urging state officials to develop a strategy for identifying families who were incorrectly denied coverage. The state should attempt to enroll as many of them as possible, said the resolution from the group, which represents 35 Wisconsin health agencies and advises the state on public health matters.

A copy of the resolution was sent last week to Gov. Jim Doyle and Department of Health and Family Services Secretary Helene Nelson.

Nelson said she believes the computer error affected only a small number of people, many of whom are already in the system but were put in the wrong program at one time.

"Our general approach to that is, instead of trying to go backward in years of old records, get the word out now and do what we can to help people get health insurance for their kids and themselves," Nelson said.

Rep. Kitty Rhoades (R-Hudson), a member of the Legislature's Joint Finance Committee, agreed that it was impractical for the state to go back and review the applications of everyone who was denied coverage.

But "if they're eligible, they're eligible," Rhoades said, adding that the state would need to find a way to pay for new participants if enrollment numbers dramatically increase.

There were nearly 546,900 people enrolled in Wisconsin's family Medicaid programs in September 2005, up 5% from a year earlier.

The state realized its computer system for processing Medicaid applications was improperly evaluating many cases and in 1999 ordered social workers to manually calculate eligibility.

Though community advocates had long complained about the problem, the state didn't reprogram the computer system to fix it until July 2004, nearly five years after the problem was identified.

In January 2004, the month studied in an audit by the non-partisan Legislative Audit Bureau, the glitch resulted in 1,100 people being improperly denied access to the health care program; nearly all of them were children, the audit said.

Nelson said state health officials don't believe the number was that high.

Malisa Tollefson of Cushing, in northwestern Wisconsin, was one of those who was improperly denied.

Tollefson was pregnant with her daughter in mid-2004 when she applied for prenatal health care coverage through the state's Healthy Start program, but was initially turned down.

Frightened about mounting bills when she received the $173 bill for her first checkup, Tollefson went back to a Polk County family health benefits counselor who reviewed her case and quickly saw that she did indeed qualify.

Not everyone is as lucky as Tollefson to find a case worker willing to take a second look, Rust said, adding that he believes many simply gave up trying to receive coverage when they are first denied.

"Most people go away," Rust said.

Nelson said that the department has taken extra efforts in recent months to be sure eligible residents are enrolled in the appropriate programs, sending a mobile van into communities and creating a Web site to help people sign up.

"I don't think that there are people out there in any numbers who, due to a computer glitch five years ago, aren't getting coverage today," Nelson said.