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Early intervention services at-risk after state takes over billing system

A service for special needs infants and toddlers may be in jeopardy as providers, who haven't been paid in months, struggle to balance the books.
Syracuse (WSYR-TV) - A service for special needs infants and toddlers may be in jeopardy as providers, who haven't been paid in months, struggle to balance the books.

The Early Intervention Program used to be billed through counties. In an effort to cut expenses for local governments, New York State enacted a new billing and payment system on April 1, 2013.

Since then, less than 20 percent of claims to private insurers have been satisfied.

Therapists and other providers in the program are now required to bill insurers through a fiscal agent contracted by the New York State Department of Health (NYSDOH).

"They put in such a convoluted billing process that none of us at this point are getting paid. It's just been a nightmare in terms of seeking any type of reimbursement," said Bob Trapani with the New York State Occupational Therapy Association. "If the state was going to assume the responsibility of billing, they really should have put an effective plan in place before they did it."

The kink in the system has put special programs at risk for children under the age of three, who qualify for services including occupational, speech, physical and educational therapies.

“In the last week, I've spent at least three hours on the phone with an insurance company and that is three hours that I am not spending directly with children doing therapy," said Margaret Bacon, a speech language pathologist.

Bacon never had to negotiate with insurance companies before the new system was enacted and says the state didn't offer any training.

A few months ago, Lindsay Swab noticed Bacon wasn't getting paid to treat her son Nathaniel.

"I was worried that she would stop seeing him because if you aren't getting paid, four months is a long time to go without getting paid," Swab recalled. "I worry that other kids that are getting into the system, [therapists] might not want to see them because they have insurance."

Bacon has agreed to keep treating Nathaniel as long as he is eligible for Early Intervention Services. He's scheduled to transition to a new program next month.

She's still concerned about long-term reimbursements from other clients.

"I have three children that I work with who have insurance that I haven't been paid for. With Nathaniel alone, in the last four months, I haven't been paid and that is 52 visits," said Bacon.

Nearly 70,000 children were served in the program in 2011-2012. Health officials say nearly a third of the children enrolled over the years have had some form of private insurance coverage, but insurers have paid 2 percent of the costs of services.

The state and county cover what insurance companies do not reimburse.

“Because of the lack of reimbursement for the service we're providing agencies, small business are starting to close, children are going on waiting lists, and that is starting to trickle down to Central New York," said Trapani.

NYSDOH has issued more than $133 million to providers since April 1, 2013. With nearly 400,000 claims submitted, about 75,000 have been satisfied.

Even in cases where reimbursement attempts were made, Bacon says there were some flaws in the system.

"I have colleagues who I work with that checks are coming in and families are getting checks and they don't know why they are getting the checks and they are spending the checks," Bacon explained.

Health officials acknowledged the problem in a release sent to media on Tuesday:
"Regrettably, many insurers have been incorrectly issuing payments to families or other therapists, not sending the required information about the results of the claim adjudication process to DOH’s fiscal agent, or not responding to claims at all."

In late July, county officials were asked to consider issuing "Preliminary Escrow Payments" to providers using the Early Intervention Program Funding. Most declined to participate.

Hours after NewsChannel 9 contacted the health department with a list of questions, officials announced a plan to temporarily reimburse some missed payments, while the kinks of the new system are worked out.

Under what's being described as a "safety net" payment, providers will receive 75 percent of unpaid claims from April through July. Those payments would be reconciled between October 2013 and July 2014.

It is unclear how the state plans to resolve issues with claims made in August and beyond. Trapani believes "safety net" payments are a band-aid that won't fix a broken system.

For additional information, Early Intervention providers may contact DOH’s Bureau of Early Intervention at (518) 473-7016.

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