Accenture Financial Review Background Information
Problem Overview
Since Accenture assumed responsibility for eligibility application processing, HHSC's clients have experienced serious problems with the system-problems that left 81,504 Texas children without medical coverage between December 2005 and August 2006. Interviews and correspondence with HHSC clients and staff, community organizations, legislators and advocacy groups yielded some common themes. The sum total of client experiences point to three basic causes:
- system problems, both with HHSC's TIERS and Maximus' MAXe systems;
- inadequate and poorly trained staff; [1] and
- sweeping and poorly implemented policy changes.
One could debate which factor has had the greatest impact on declining CHIP and children's Medicaid caseloads, but since HHSC does not track complaints and appeals adequately, the reality is that neither the Comptroller's review team, the Legislature nor HHSC itself can know. It is apparent, however, that HHSC has been ineffective in preventing such problems from occurring again and again.
Among the problems repeatedly reported by clients and other stakeholders:
Accenture and its subcontractors have lost applications and then asked applicants to submit the same form again, often on multiple occasions.
Many applicants reported that they have been forced to submit the same information multiple times.[2] Several also reported finding it difficult to have information sent to a new address, despite having submitted the new address several times.[3]
The most common theme among applicant complaints has been disenrollment due to their failure to provide required information in time during the application process.
As part of its new CHIP policies, HHSC began requiring families to submit detailed income and asset documentation, such as pay stubs and bank account statements, at renewal times beginning in January 2006. According to HHSC, there has been a significant increase in incomplete renewal packets since January 2006.[4]
Accenture has made multiple data requests of applicants, sometimes asking for the same information, sometimes asking for more information after each response.
Repeated information requests can discourage applicants and spur them to drop out of the process. In CHIP renewals, moreover, these endless data requests can cause applicants to run out of time and lose coverage.[5]
As one father explained, "I have been trying to get Medicaid for my daughter.... They initially received my application on Feb. 23, 2006. I have been told for the past few months that I have missing information...over and over and over. It's the same information I have given them time and again."[6]
One mother of a ten year old girl with rapidly progressing scoliosis was told to provide missing information three times in March and April 2006. Each time she was asked to provide different missing information. Each time she spoke with a different operator who had no knowledge of her case. She faxed her pay check on the same page as her husband's, but was told that the contractor had received her pay stub, but not her husband's.
Later, she was told to obtain a letter from her husband's employer verifying his place of employment, even though she had already submitted his latest pay stub as required. Then she was instructed to provide notification in writing that the family did not receive child support or alimony payments. As a result of these delays, she was forced to cancel an appointment with a specialist for her daughter on May 23, because her CHIP coverage had not been renewed. [7]
Accenture has sent clients letters demanding information or enrollment fees by a date set before the date of the letter.
One person applying for children's Medicaid received a letter from Accenture dated May 8, 2006 that required information to be returned by April 15, 2006.[8] Another applicant received a letter dated May 3, 2006 that required information to be returned by March 26, 2006.[9] Appendix 4 contains copies of these letters.
Accenture has assessed eligibility inaccurately.
One CHIP applicant seeking renewal provided Accenture with self-employment documentation, including his 2005 federal tax return form 1040 and Schedule C-EZ. He did not have a Schedule C because the IRS requires a Schedule C-EZ instead of the Schedule C if business expenses are $5,000 or less. Even so, Accenture notified the applicant that it would not accept the Schedule C-EZ―even though that is what the IRS requires.[10]
Another CHIP applicant complained that an inaccuracy in how Accenture calculated her income would "leave her children without insurance for a couple weeks, maybe months, for a calculation error they committed." The mother repeatedly appealed for review of her application but Accenture told her it might take months to reinstate her children, even though the company was at fault.[11]
Accenture has provided clients with inaccurate, contradictory, confusing or incomplete instructions.
One father trying to enroll his daughter in CHIP received a letter citing an inaccurate payment deadline, two weeks later than the actual deadline. Although the father sent in a check that was cashed, Accenture considered the payment late and dropped his daughter from CHIP. The father fought for two months to get his daughter reinstated. During this time, his daughter suffered a second-degree burn and could not return to school without a note from her doctor―which was not available until her coverage was restored.[12]
HHSC has failed to clearly communicate major CHIP policy changes to enrolled families and the community-based organizations that assist them with CHIP applications and renewals.
Many families and community groups were not aware that HHSC had reinstated CHIP enrollment fees and required additional verifications for renewals.[13]
Many clients who contact the call center have been left on hold for lengthy periods, encouraging them to abandon their attempts to obtain service.
The Accenture contract requires that fewer than 5 percent of the call center's clients should abandon their calls before receiving assistance. Beginning in January 2006, one month after Accenture took over CHIP processing, the call center's abandonment rate rose to 6 percent. By February the abandonment rate nearly doubled, to 11.7 percent; by April, it nearly doubled again, to 22.6 percent.
The contract also stipulates that callers should not be put on hold for more than two minutes. According to Accenture's Key Performance Report for April 2006, hold times average more than five minutes in February and more than 11 minutes in March.[14] By April, shortly before the Comptroller was asked to review the contract, CHIP applicants were reporting hold times of 30 minutes or longer.[15]
The call center has provided incorrect or confusing information.
Staff from the U.S. Department of Agriculture (USDA), the federal department that administers the food stamp program, listened to 20 recordings of actual calls received at the call center and reported that vendor personnel of the integrated eligibility program often provided incorrect or confusing information; sent clients to the wrong certification office; failed to provide information on the complaint process; and garbled information about appointments.[16]
After months of trying to have her children's CHIP coverage renewed, one mother reported receiving three letters from Accenture on May 5. One letter, dated May 1, informed her that her children's coverage had been cancelled because she had not completed the renewal paperwork. A second letter, dated May 2, provided for continuation of coverage as of June 1, stating that her renewal information had been received but that her coverage would lapse for one full month. The third letter, also dated May 2, contained an initial enrollment packet and form, as if her children had never had coverage before.[17]
Accenture and HHSC have failed to notify CHIP parents of their loss of coverage.
One mother completed her renewal application and sent it in on January 4, 2006, to renew CHIP eligibility for March 3, 2006. Accenture marked her case as pending because she owed an enrollment fee of $25, but did not notify her of this. The mother called Accenture on March 3, 2006, to find out why she had not received an enrollment packet and learned that the case was still pending.[18]
Some CHIP parents reported that they did not know that their children had lost their coverage until a doctor or pharmacist told them. This meant that parents with chronically ill children often found that they did not have the coverage they needed to pay for ongoing care. HHSC has responded to this common problem by implying that its clients must have received notification and must be mistaken.[19]
Lapses in CHIP health insurance coverage caused by vendor error cause renewals to be treated as new applications, which could deprive the child of health care coverage for at least 90 days.
If CHIP health insurance coverage is not renewed promptly, the 90-day introductory period for "new" coverage can cause gaps in medication and health care services. One mother reported that she struggled from February 7, 2006 to May 2, 2006 to renew her diabetic son's CHIP coverage. After numerous attempts to have her child enrolled and repeated requests for different "missing information," she received a letter on May 2 denying eligibility. She filed an appeal, but was then told her application had been accepted.
Its effective date, however, was August 8, 2006, so her son would not have coverage for three months. She called and was told that there is a three-month waiting period on all new applications. As she explains, "I inquired as to the appeal and was told that when the application was accepted, the appeal was then terminated. No one had EVER told me that."[20]
Another applicant changed jobs and enrolled her daughter in CHIP but kept her son on Medicaid. Although this woman knew that, in her new job, she made too much money to keep her son on Medicaid, Accenture would not transfer him to CHIP until they released her son from Medicaid enrollment. This delay caused her to miss the CHIP enrollment deadline; her son was without coverage for six months.
In an interview with the review team, she said, "My children's drug bill is over $300 a month. I am caught in the company's confusion and the result was my son was without health insurance. I had to give my children their medication every other day to stretch it out because I couldn't afford it."[21]
Accenture and HHSC have been unable to resolve applicant problems promptly.
One mother of an asthmatic son had to send her son's CHIP forms several times while her son and his medications remained without coverage. She said, "I asked a number of times to talk to a supervisor or to talk to someone in the department that could help me but nobody could do anything, and they all said that they were sorry, but nothing could be done. I was frustrated, mad and utterly disgusted by the fact they cared more about paperwork than my son's health. At no point was anyone at CHIP concerned with the fact that my child was ill and now running out of his medicine."[22]
A grandfather, Richard Uhr, testified at a recent legislative hearing that it took more than six months to obtain CHIP coverage for his grandson.[23] At the time of his testimony, he believed his grandson was finally on CHIP, but after the hearing he received a letter from Accenture indicating that the family still needed to provide some missing information, or his grandson would not be enrolled. According to newspaper reports, state officials said the grandson would continue getting CHIP insurance coverage, and attributed the mistake to the contractor.
Accenture and HHSC have made it difficult for applicants to complain.
One parent was instructed by a supervisor she needed to speak to a "higher up" to resolve her appeal and reinstate her children in CHIP but was denied the opportunity because they were "in meetings." The supervisor offered to e-mail the information and said someone higher up would call the parent back. It never happened. When the parent called back to ask again if she could talk with a "higher up," she was told that they were again "in meetings."[24] As one father stated, "I can't get past the phone reps to talk to a supervisor. They have refused to let me speak with anyone higher up. I would like to know what is going on with my daughter's application. I'm desperate to get her insured."[25]
Another parent began the CHIP renewal process for her son in December 2005, to ensure that her son's coverage would continue for the next period that began on April 1, 2006. Despite repeated calls and correspondence, and meeting all fee and documentation requirements, her son was denied CHIP benefits. This woman told the review team, "I called the CHIP 1-800 number and did not get anywhere or get any information by doing this. I couldn't reach anyone after I asked to talk with a supervisor and no one would call me back. I was told to call my legislators. I called them both and one called me right back." After her legislator became involved, her son's CHIP benefits were restored retroactively, but she was not reimbursed for out-of-pocket expenses she incurred in the meantime.[26]
Appendix 4 provides examples of letters Accenture has sent to clients.
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CASE STUDY "Stuck" between CHIP and Medicaid |
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One mother had a three-year-old enrolled in CHIP and a one-year-old receiving Medicaid coverage. The three-year-old is asthmatic and on medication and needs additional medical treatment for sporadic breathing problems. The mother received the CHIP renewal packet and returned it on January 15, 2006, so that her older son's coverage could renew in March 2006. At the end of February, she received a letter from Accenture stating that the program had not received her application. Upon contacting the call center, a representative told her that the program had in fact received her application on January 3, that it was complete and that it would be sent to the work queue. The customer service representative advised her to call back in a week. She called back after another week and spoke with another representative who told her to write a letter of appeal, because by that time her March 2006 renewal was about to lapse. She was told that an appeal would take two more weeks. When she called back, two weeks later, she was told no one had received her faxed appeal. In the meantime, her older son's coverage had ended and he had become sick. She faxed another letter of appeal. After several more weeks, the mother received a phone call informing her that she was "stuck" between CHIP and Medicaid due to a computer problem; it seemed her income was too low to qualify for CHIP, so the program sent her application to Medicaid. Accenture and HHSC then decided that she had too many assets to qualify for Medicaid, but that her children did qualify for CHIP after all. She was told, however, that the system would not recognize this decision, so Accenture staff would have to override it manually to make sure her son was covered. Accenture sent her a new enrollment packet that was due April 22; she received it on April 23. She filled it out and faxed it in anyway. Upon making a follow-up call, she was told that the information had been received and that Medicaid was sending information about her younger son so that his CHIP coverage could start in May. (Medicaid coverage for many newborns ends after they are a year old.) About a week later, at the end of April, she received a letter from Accenture saying that both boys' CHIP insurance would start on May 1, 2006, and that she could use the letter at the doctor's office and pharmacy until their insurance cards came in the mail. On May 2, 2006, she took her asthmatic son to the doctor, where she learned that the boy still did not have insurance. She called Accenture and was told that her older son did not have CHIP coverage because she had not filled in a portion of the CHIP HMO enrollment form identifying her younger son's plan provider and primary care provider, and that she should have filled out her younger son's information when she sent in her older son's enrollment packet―even though he was still covered by Medicaid at the time. |
Endnotes
[1] Health and Human Services Commission, "Presentation to the House Appropriations Subcommittee on Health & Human Services," Austin, Texas, April 17, 2006, pp. 15, 17; and Letter from William Ludwig, regional administrator, U.S. Department of Agriculture, Food and Nutrition Service, to Albert Hawkins, executive commissioner, Health and Human Services Commission, April 5, 2006.
[2] Letter from a caseworker at Safe Place to the Health and Human Services Commission, April 28, 2006.
[3] Letter from a CHIP applicant to the Health and Human Services Commission, Children's Health Insurance Program, May 24, 2006.
[4] Memorandum from Albert Hawkins, executive director, Health and Human Services Commission, to the members of the House Appropriations Committee, Subcommittee on Health and Human Services, April 21, 2006, p. 5.
[5] Children's Defense Fund, "The Children's Health Insurance Program," Washington, D.C., July 25, 2006. (Informational pamphlet.)
[6] Email from Medicaid applicant to Health and Human Services Commission, May 2, 2006.
[7] Children's Defense Fund of Texas, "Case Study: Abigail Espinosa, Mission, Texas, Ten Year Old Girl with Rapidly Progressing Scoliosis," Austin, Texas, June 2006.
[8] Letter from the Health and Human Services Commission to a benefits applicant, May 8, 2006.
[9] Letter from the Health and Human Services Commission to a benefits applicant, May 3, 2006.
[10] Interview with CHIP applicant, August 22, 2006.
[11] Letter from a CHIP applicant, April 26, 2006.
[12] Letter from State Senator Eliot Shapleigh, May 10, 2006, p. 4.
[13] Children's Defense Fund of Texas, "Immediate State Action Requested to Address CHIP Enrollment Loss," http://www.cdftexas.org. (Last visited on August 18, 2006) (Petition.)
[14] Texas Access Alliance, Texas Integrated Eligibility and Enrollment Services KPR 68―Monthly Monitoring Report (Austin, Texas, May 19, 2006.), p. 33.
[15] Letter from a CHIP participant's mother, May 15, 2006.
[16] Letter from William Ludwig, Food and Nutrition Service, to Albert Hawkins, Health and Human Services Commission, April 5, 2006.
[17] Letter from a CHIP participant's mother, May 15, 2006.
[18] Texas Access Alliance, "Complaint Case File," Austin, Texas, March 9, 2006. (Computer printout.)
[19] Testimony of Anne Heiligenstein, deputy executive commissioner, Health and Human Services Commission, before the Texas House of Representatives, Committee on Government Reform, Austin, Texas, July 26, 2006, http://www.house.state.tx.us/committees/broadcasts.php?session=79&cmte=285. (Last visited August 8, 2006.)
[20] Letter from a CHIP applicant's mother, May 12, 2006.
[21] Interview with a CHIP applicant's mother, August 23, 2006.
[22] Letter of complaint reported to the Center for Public Policy Priorities, May 2006.
[23] Testimony of Richard Uhr before the Texas House of Representatives, Committee on Government Reform (Austin, Texas, July 26, 2006), http://www.house.state.tx.us/committees/broadcasts.php?session=79&cmte=285 (Last visited August 8, 2006).
[24] Letter of complaint reported to the Center for Public Policy Priorities, April 26, 2006.
[25] Email from Medicaid applicant to Health and Human Services Commission, May 2, 2006.
[26] Interview with a CHIP applicant's mother, August 22, 2006.