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Poor training, supervision and management have continued to plague county systems for getting people signed up for Medicaid.
By Rose Hoban
Signing up Medicaid recipients quickly and accurately without improperly denying benefits is still a struggle for many county social service workers, according to a review released Thursday from the office of State Auditor Beth Wood.
Many county social service workers continue to struggle to get Medicaid recipients signed up for the program quickly, they make mistakes in enrolling beneficiaries and deny benefits to people they shouldn’t. That’s according to a review released Thursday from the office of State Auditor Beth Wood.
In an audit of about 2,000 cases in 10 counties across the state, Wood’s reviewers found that high staff turnover, a steep learning curve for operating state computer systems, and a lack of supervision contributed to the problems.
In addition, auditors said the Department of Health and Human Services did not require county employees, who do the enrollment work, to train on the computer system known as NC FAST.
The computer system should make it easier for county social service workers to enroll recipients in a variety of benefit programs. But since early 2014 the system has generated problems with payments from the Supplemental Nutrition Assistance Program, commonly known as food stamps. There were also huge backlogs of Medicaid applications in 2014 that prompted federal officials to issue a warning letter to the state about the delays.
Then in 2016, Wood’s office found continued problems with overworked county workers struggling with piles of applications for Medicaid and other benefits.
The persistent problems lead the state General Assembly to draft a bill last year that would allow DHHS to temporarily take over a county social services department that had persistent backlogs. Legislators put the bill on hold, choosing instead to see what the auditor found.
Thursday’s report is likely to reopen that discussion.
The audit found some counties do a much better job than others.
Wood’s audit looked at three urban counties, Guilford, Mecklenburg and Wake, suburban Rowan County and six rural counties, Jones, Madison, Rutherford, Vance, Washington and Wilkes. Results were all over the map (see tables).
One standout was Wilkes County which consistently had the best performance of the ten counties. In almost all the measures, Wilkes had the lowest error rates and the fastest turnaround times for eligibility determinations.
“We double tested [Wilkes County] because their numbers were so favorable and I think it’s safe to say they’re one of the poorer counties,” Wood said. “So we took a look at how is it that could happen and that’s because they had robust procedures in place to make sure they were … accurate.”
Timeliness is more than just a bureaucratic problem. Delayed applications mean that “the State likely paid for Medicaid benefits for which the recipient was not eligible,” Wood noted.
And when denial error rates go up, “some residents were likely denied medical services for which they were eligible.”
For instance, Vance had an erroneous denial rate of 38.1 percent.
State funded, county run
One of the difficult features of North Carolina’s social service system is that the state provides the funding and is ultimately responsible for performance, but county employees do the actual work.
And each county does that work just a little bit differently, Wood said.
“I could not take a statistical sample from 1.9 million Medicaid recipients and do the review because every county is different,” Wood told NC Health News. Instead, her office had to take 250 files from each of the 10 counties and go through them separately.
“This is not how it’s supposed to work. We couldn’t do an apples to apples comparison,” Wood said.
Ultimately, she said she can’t make a sweeping statement about how the state is performing because she only feels confident of the results in those 10 counties.
“It’s difficult to tell [legislators] what they need to know,” she said.
In the departmental response to the audit, former Secretary Rick Brajer said he agreed with Wood’s findings and noted that last summer, DHHS required each county social service office to create quality assurance plans. In their responses, county DSS heads also agreed with Wood and detailed the measures they’ve taken to improve.
He said the department would require counties to use standardized training materials for NC FAST and provide more in-depth training for county workers. The legislature also appropriated funds in 2015 to provide seven staff members to train and support county workers across the state.
But Wood had a larger message for the Department, that leaders need to take responsibility for what’s happening at the county level.
“We haven’t insured consistency in the eligibility determination of possible participants. They haven’t done a good job in making sure it’s being determined accurately and timely across 100 counties.”
Wood said the General Assembly needs to alter state laws to “reinforce that the Department has the ultimate responsibility for the accurate and timely determination of eligibility for participants in the Medicaid program.”
In an email response, a representative from the North Carolina Association of County Social Service Directors said the organization had only just received the audit and needed time to process the findings.