I Love Medicaid Encounters

Having worked for a great PBM experiencing the joys and challenges of architecting Medicaid encounters systems for health plans in several states, I learned

• Medicaid encounters look simple but they’re not.
• PBM’s typically start out with young developers on the cheap with specific skills with specific versions of specific software and burn them out every 3 to 6 months.
• Millions of dollars in sanctions are lost.
• Millions of dollars in reinsurance revenue is lost.
• Company reputation suffers and business is lost.
• Bringing in a new health plan takes weeks if not months or years longer than it should.
• Massive corrections and late submissions of missed encounters take place.
• Auditors visit the PBM to compare claims to payables and receivables.
• Red hot priorities are interrupted for redder and hotter priorities.
• Meanwhile, periodic operations, corrections, strategic and tactical improvements must continue in parallel according to business impact and compliance requirements.
• Managers have the eyes of the entire corporate pantheon on them.
• Managers and staff members get fired and replaced.
• Then some crazy person like me gets hired, enjoys the challenge, and becomes the first person to hang in there long enough to get things straightened out. Continue reading “I Love Medicaid Encounters” »

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