Year: 2017

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Medicaid Acronym of the Day – ABN

Advance Beneficiary Notice – The ABN is a written notice you must issue to a Fee-For-Service beneficiary before furnishing items or services that are usually covered by Medicare but are not expected to be paid in a specific instance for certain reasons, such as lack of medical necessity. The ABN allows the beneficiary to make an informed decision about whether to get the item or service that may not be covered and accept financial responsibility if Medicare does not pay. If the beneficiary does not get written notice when it is required, he or she may not be held financially liable if Medicare denies payment, and you may be financially liable if Medicare does not pay. The ABN is used for Medicare Part B (outpatient) and Part A (limited to hospice, Home Health Agencies, and Religious Nonmedical Health Care Institutions only) items and services.

Further reading 

https://www.medicare.gov/claims-and-appeals/medicare-rights/abn/advance-notice-of-noncoverage.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/abn_booklet_icn006266.pdf

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Weekly Medicaid RoundUp: Week of July 24th, 2017

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2vdvt9S

For optimist readers-  http://bit.ly/2v3Ugx6

 

CHECK FOR A PULSE-  Looks like Obamacare lives to skyrocket premiums another day (for those of us who still pay premiums, anyway). The Senate’s Skinny Repeal got shot down 51-49, with John McCain helping nix it along with two other Republicans. The night came with high drama, including a call from Trump to McCain (with Pence handing him the phone). McConnel is reported to have said “its time to move on.” My prediction: its done (at least for a long time).

 

BAY STATE BUSINESSES SUPER EXCITED TO PAY $300M IN FEES TO FUND INCREASING MEDICAID COSTS- Your reward as an employer in MA for providing jobs? Paying your employees’ healthcare costs AND $2k per employee to cover any Medicaid bennies on your payroll. Best. Plan. Ever. It’s a wonderful thing for politicians that 99% of Americans hated high school econ. The Good Guvn’r Baker’s plan is being scaled back, but not dead yet. If you want a vision of the future, imagine a boot stamping on a human face – forever. (Orwell)
TAKING IT UP A NOTCH- You know all those wacky states trying to add work requirements for non-disabled, non-elderly Medicaid bennies? Well if Senator John Kennedy of LA (cool name, rings a bell) has his way, Federal Medicaid regs will be changed to require it nationwide. Put this one on your watch list.

 

I WILL GLADLY PAY YOU ON TUESDAY FOR A HAMBURGER TODAY – IL finally started to pay some of the MCO tab last week – $750M in back payments went to plans. Now only about $3.5B more to go to get square. Reality is that which, when you stop believing in it, doesn’t go away. (Philip K. Dick)

 

ARKANSAS TRYING TO RESTORE COVERAGE FOR 2,000 IMMIGRANT CHILDREN EXLCUDED FROM MEDICAID BY BILL CLINTON- AR has about 12,000 Marshallese (The Marshall Islands) who got in under a 1986 law. Thing is Bill Clinton’s welfare reform (yeah, he did that) nixed any Medicaid coverage for them. AR DHS submitted a proposal to undo the Clinton coverage ban this week for the kids.

 

FLICKERTAIL STATE WILL COVER ABA FOR AUTISM- North Dakota Medicaid will cover applied behavioral analysis (ABA) for autistic children as of this week. Attempts by state reps to mandate commercial insurers in the state cover it were unsuccessful.

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. Tammie Sensenig of Denver, PA was sentenced this week to 4 years in prison. She already had a Medicaid fraud conviction, but lied about it and forged a background check when she got a new job as a behavioral health consultant for a company that provides Medicaid services. PA paid out $84k to the already-barred provider. Bharat Patel’s case this week in Norwalk, CT included video of him writing scripts in exchange for cash. He’s accused of stealing $4M from Medicaid by selling scripts to addicts. Meridian Senior Living Group in NC is being prosecuted for a $60M Medicaid fraud, based on comparing staffing levels to billable hours (hint -there’s not enough staff and too many billable hours). Meridian you win this week’s award by a mile! Total taxpayer tab this week: $64.8M. There was a lot more in Medicare but we stick to Caid here!

I WILL BE AT MESC IN A FEW WEEKS, WILL YOU? If so send me a note and let’s meet up.

I WILL BE AT MHPA 2017 IN OCT., WILL YOU? You can check it out here – http://bit.ly/2twCi5L Every 100th registrant will get a free Medicaid Foundations Course registration (our online training course).

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (It is nearly August and August is hot! Want to read Light in August with me? If 3 or more write in we’ll do a book club on it) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Chichi wa sekai o sukuu tame ni musuko o okurimashita

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Medicaid Acronym of the Day – AAPC

American Association of Professional Coders – a professional association for people working in specific areas of administration within healthcare businesses in the United States.[5] AAPC is one of a number of providers who offer services such as certification and training to medical coders,[4] medical billers, auditors, compliance managers, and practice managers in the United States. Currently, AAPC has over 155,000 worldwide members,[6] of which nearly 108,000 are certified.

Further reading 

https://en.wikipedia.org/wiki/AAPC_(healthcare)

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Medicaid Acronym of the Day – CDC1

Comprehensive Diabetes Care A1c Testing – The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each of the following:

•  Hemoglobin A1c (HbA1c) testing.

•  HbA1c poor control (>9.0%).

•  HbA1c control (<8.0%).

Further reading 

 https://www.qualitymeasures.ahrq.gov/summaries/summary/49717/comprehensive-diabetes-care-percentage-of-members-18-to-75-years-of-age-with-diabetes-type-1-and-type-2-whose-most-recent-hemoglobin-a1c-hba1c-level-is-greater-than-90-poorly-controlled

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Medicaid Acronym of the Day – CCS

Cervical Cancer Screening – The percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria:

• Women age 21–64 who had cervical cytology performed every 3 years.

• Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.

Further reading 

http://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality/2016-table-of-contents/cervical-cancer-screening

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Medicaid Industry Who’s Who Series: Preston Cody

Preston Cody is the featured panelist for the upcoming Washington State Medicaid Spotlight Webinar on Monday, August 7th. RESERVE your seat today!

 

Medicaid Who’s Who: Preston Cody – Division Director, Division of Medicaid Program Operations and Integrity, Washington State

 1.  What segment of the industry are you currently involved?

A: Medicaid Program Integrity, Medicaid Managed Care, value-based payment, network adequacy, physical/behavioral health integration, mental health parity, Medicaid Administrative Claiming, Non-emergency Medical Transportation, Interpreter Services, and other activities related to Medicaid Program operations.

 2.  What is your current position and with what organization?

A: Division Director, Division of Medicaid Program Operations and Integrity, Washington State Health Care Authority (the single state Medicaid agency in WA)

 3.  How many years have you been in the Medicaid industry?

A:  20+

 4.  What is your focus/passion? (Industry related or not)

A:  I’m passionate about ensuring the clients we serve receive the best care possible and those staff who serve clients on a daily basis get the direction, tools and support to do their jobs effectively with a high-level of satisfaction. As a veteran I serve as the executive sponsor for the agencies Veterans Employee Resource Group which focuses on recruiting, retaining and supporting our veteran employees. I find this an extremely rewarding process.

 5.  What is the top item on your “bucket list?”

A: Simply to live each day to the fullest and enjoy the journey.

 6.  What do you enjoy doing most with your personal time?

A:  On a personal note, I am happily married and have five children and two grandchildren who I love spending time with. My family and I love to camp, boat and ride ATV’s on the Pacific Northwest coast, it’s an amazing place to live! However, during football season we switch gears to watch our beloved Seattle Seahawks. Go Hawks! Work-life balance is critically important and something we encourage staff to focus on in our agency.

 7.  What is your favorite junk food?

A:  Any type of Mexican food, it’s all amazing!

 8.  Of what accomplishment are you most proud?

A: Effectively transition the WA State subsidized Basic Health program to Medicaid coverage under the ACA effective 1/1/2014.

 9. For what one thing do you wish you could get a mulligan?

A: Great question. Years ago our organization was directed by our state Legislature to immediately terminate coverage for a large group of clients with less than 1 day notice. We complied with the requirement which was immediately challenged and was ultimately settled years later. If I had the opportunity for a do over I would have done a better job describing the impact and delaying implementation which would have accomplished the same outcome with far less disruption and ensured clients received timely due process.   

 10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months? 

A:  1.  Ensuring there is no erosion of coverage resulting in a decrease in population health, increased uncompensated care and massive disruption in the health care system.

2.   Effective implementation of behavioral and physical health integration in WA Medicaid.

3.   Completion of the first year of value-based payment requirements with our managed care organizations.

Preston Cody is the featured panelist for the upcoming Washington State Medicaid Spotlight Webinar on Monday, August 7th. RESERVE your seat today!