Author: MM_ADMIN

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Clay’s Weekly Medicaid RoundUp: Week of July 1st, 2019

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

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

HAPPY BIRTHDAY TO YOU- Happy birthday to you. Happy birthday, dear America- Happy birthday to you!

RATES? WE DON’T NEED NO STINKIN’ RATES- On July 1, MCOs in Iowa began another fiscal year without official capitation rates (the same thing happened last year- it was 2 months before rates got locked down then). Last time this happened it didn’t turn out too bad for MCOs, though: They got an 8.4% bump.

CMS FUNDING NEW OPIOID TREATMENT GRANTS- CMS announced new $50M grants available for states to improve substance abuse treatment and recovery efforts. The feds are looking for proposals that would fund 18-month pilots. Applications due August 9th.

PRAIRIE STATE OWES FEDS LOTS OF DOUGH- Seems Iowa did not collect rebates on about $7M worth of Medicaid drugs. Federal HHS IG sent a letter looking to collect on the $4M federal share of those rebates. HHS has been reviewing state rebate collections, with Illinois being the 36th state to have its tires kicked. NJ has been asked to pay back $8M.

SOONER STATE DOES, TOO- Oklahoma had some recent success suing Purdue Pharma. By success, I mean they got a settlement of $270M awarded (all related to Purdue’s OxyContin marketing practices, I think). Well someone at CMS saw the news and sent a letter to OK Medicaid making sure they knew the feds were entitled to some of that money. The Good Guvnr Stitt is currently saying no dice, federalis.

NH TWEAKING WORK REQUIREMENTS- Dem state reps have been trying to undo the deal they made to keep expansion going. Looks like a compromise is being struck- the requirements stay, but there are now no penalties for non-compliance.

AK TIGHTENING THE BELT- The Good Guvnr Dunleavy is cutting $444M from the overall state budget, with $50M of it coming from Medicaid. Here is a quote that will strike terror in the heart of Medicaid-industry lifers: “Cost-saving measures can be achieved in the Medicaid program through creativity, program reform, and focusing on fraud.” What the heck does he mean cost savings through creativity? Reform? Focusing on fraud? How dare he?! Has no one told him yet the way Medicaid actually works? Someone talk to this man!

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award. Brenda Copeland of Warner Robbins, GA stole near bouts $500k using her counseling business. She was charged this week with filing false claims (and I think it may have been to an MCO, but not sure. If you are, please weigh in). Move on up and over to Pulaski County, Arkansas where we meet Charline Brandon. She has to pay back $289k to AR Medicaid for tricking patients into thinking they were dying so they would sign up for hospice (that’s a particularly special kind of cruel). One victim spent 3 years in hospice. For another entry in the despicable department, head back east to Greensboro, NC. Here we meet the good people at United Care Youth Services. According to allegations made by patients, this outfit is requiring people to stay hooked on drugs so they can stay in their housing program. Plaintiffs say they were provided free or reduced housing as long as they did not have 3 clean, consecutive drug tests. The organization also provided classes and substance abuse treatment, then billed it to Medicaid. As of the time of writing all allegations were being denied but state investigators are looking into this and other similar schemes. Ann Eldridge and Angela Keith of Sumter, SC are wrapping up their court adventure over their pilfering of $13M from Medicaid. How did they do it, you ask? Using their organization (Early Autism Project) to bill false claims over a 9-year period. The two ladies ended up getting 6 months in prison… Ok enough southern-fried fraud- lets move this party up North. Crispin Abarientos of Middletown, CT plead guilty to getting $894k worth of Remicade (an injectable used for rheumatoid arthritis) using false claims to Medicaid. He then turned around and used that Remicade on commercial or Medicare members and got paid by those payers. So get some “free” Remicade (paid for by Medicaid-funding citizens), then sell it to Medicare and commercial plans. Total taxpayer tab (grin and bear it, you suckers!) for this paragraph: $14.7M. Our illustrious ladies from South Carolina (Mrs Eldridge and Mrs Keith), you win this week’s award.

 

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 (stare long and hard at those almost-ready tomatoes) 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: Chúa Cha đã sai Con đến cứu thế gian.

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Monday Morning Medicaid Must Reads: July 1st, 2019

Helping you consider differing viewpoints. Before it’s illegal.
other MMRS – http://bit.ly/2T7CP7K
In this issue…

Article 1:       Trump’s Medicare chief, in Chicago, slams ‘Medicare for All’ plan: ‘We’re not going to see savings. It’s actually going to cost more. Chicago Tribune, June 11, 2019. Lisa Schencker

Clay’s summary:     Bbbbbut- Bernie! He promised me it’ll work.
Key Excerpts from the Article:
Q: The doctors who support Medicare for All say it would allow doctors and hospitals to spend less money on administration because they wouldn’t be dealing with multiple insurance companies. What are your thoughts on that argument?
A: One of the things I hear a lot is we should go to Medicare for All because of the lower administrative costs. The reality is we’re not spending enough on administration within Medicare. There’s a lot of bureaucracy that goes on with the Medicare program in terms of access to technology, protecting taxpayers against fraud and abuse and it’s because we haven’t made those investments in administering the program like you would see in the private sector.
The main issue with Medicare for All and having the government take over the entire program, is that we’re not going to see savings. It’s actually going to cost more, which means taxpayers are going to pay more, and when they’re paying more, that’s going to lead to rationing of care and problems with access to care.
Read full article in packet or at links provided

Article 2:

Puerto Rico has a post-Maria Medicaid crisis — and Congress and the White House refuse to do anything about it, RawStory

Clay’s summary:     We now have this in regular rotation in Medicaid news cycles. The key factors all center around statehood status (which ties back to the secondary issue of the federal match). Why does no one point out that the path forward on this either involves another star on the flag or independence?
Key Excerpts from the Article:
Puerto Rico has its own definition of what constitutes poverty level and that, it turns out, is much lower than the federal level.  In order to qualify for Medicaid, a family of four in Puerto Rico must show a yearly income of under the amount set as the poverty level on the island, or $10,200. That’s $850 or less a month on an island where the cost of living is higher than in most of the continental U.S. If Puerto Ricans were to qualify for Medicaid under federal poverty guidelines, they would do so as long as their income (for a family of four) did not exceed $25,750, or a little over $2,000 a month.
This means that a large number of Americans living in Puerto Rico can qualify for Medicaid if they leave the island and move to the 50 states even if their income more than doubles. Puerto Rico government officials are well aware of the problem, but lack resources to address it.
Luz E. Cruz, Medicaid director for the government of Puerto Rico acknowledged that the federal cap on Medicaid funds gives Puerto Rico limited funds and if the poverty level was raised to the level in the 50 states, more people would qualify for the program. “And that would mean that the matching portion from the government of Puerto Rico would be higher and that’s money that we don’t have right now,” she said during a brief telephone interview.
Read full article in packet or at links provided

Article 3:       Requiring People To Work To Get Medicaid Went Really Well In Arkansas Until A Judge Stopped It, The Federalist, June 10th, Victoria Eardley

Clay’s summary:     Not what you wanted to hear, I know.
Key Excerpts from the Article:
 
Since 2000, the number of able-bodied adults using Medicaid quadrupled nationwide. The program is one of the chief costs for state governments, squeezing other priorities.
When last summer Arkansas became the first state to require Medicaid recipients to work in exchange for taxpayer-provided health care, welfare advocates would have had you believing the world was ending: health coverage for the needy was being slashed, the reporting process was too complex, and those who lost coverage didn’t even know about the requirement. On and on the hysteria went.
 
But those apoplectic claims were far from reality. Arkansas’ work requirement was a big step towards restoring the state Medicaid program to its objective. It was saving taxpayers money, freeing up resources for the truly needy, and—notably—changing people’s lives for the better.
 
What critics of the requirement neglected to disclose were the thousands of people who found work as a result of the reform—some for the first time in years. These folks went from a life of government dependency to a life of independence, an undeniably better future for both themselves and their families. These are real people, with real stories, reported by the Arkansas Department of Workforce Services in late 2018.
 
Read full article in packet or at links provided
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Monday Morning Medicaid Must Reads: May 27, 2019

Helping you consider differing viewpoints. Before it’s illegal.
other MMRS – http://bit.ly/2T7CP7K
In this issue…

Article 1:      A First Look at North Carolina’s Section 1115 Medicaid Waiver’s Healthy Opportunities Pilots, KFF, May 15, 2019

Clay’s summary:     $600M to address SDoH for about 25,000 to 30,000 members. May seem steep, but its our first real attempt to measure this concept we’ve all been yapping about for 5 years.
Key Excerpts from the Article:
Medicaid funds typically cannot be used to pay for non-medical interventions that target the social determinants of health. However, in October 2018, CMS approved North Carolina’s Section 1115 waiver which provides financing for a new pilot program, called “Healthy Opportunities Pilots,” to cover evidence-based non-medical services that address specific social needs linked to health/health outcomes. The pilots will address housing instability, transportation insecurity, food insecurity, and interpersonal violence and toxic stress for a limited number of high-need enrollees.
Read full article in packet or at links provided

Article 2:      Block Granting Medicaid is Still a Terrible Idea, Suzanne Wikle, CLASP, May 15, 2019

Clay’s summary:     Op-ed writer may not realize that what she thinks is a bug is the key feature (reducing spending). Good one to have bookmarked if you are anti-block grants, though.
Key Excerpts from the Article:
While the promise of increased flexibility can sound enticing, the reality is that so-called flexibility pits funding choices against one another and ultimately leads to cuts. Medicaid already has the flexibility it needs to respond to economic downturns or public health crises, and capping funding for the program makes these responses more difficult. Block grants have not worked in the Temporary Assistance for Needy Families (TANF) program. What we know from 20 years of experience with TANF is that funding has not increased with inflation or in response to poverty and need. Moreover, states have used TANF funds to support alternative programs and have significantly decreased the aid going directly to families. Despite assurances they would fund key supports like affordable child care, policymakers haven’t been able to deliver on their promises.
Read full article in packet or at links provided

Article 3:      Medicaid could save $2.6 billion if 1% of smokers quit, Stanton Glanz, JAMA, April 17, 2019

 
Clay’s summary:      Ain’t nobody gonna tell Medicaid bennies they have to stop smoking. So we all just keep paying…
Key Excerpts from the Article:
 “Medicaid recipients smoke at higher rates than the general population … suggesting that investments to reduce smoking in this population could be associated with a reduction in Medicaid costs in the short run,” Stanton Glantz, PhD, of the Center for Tobacco Control, Research and Education at University of California, San Francisco, wrote. He noted that in fiscal year 2017, Medicaid costs totaled $577 billion. Glantz evaluated Medicaid expenditures and the economic response between changes in smoking prevalence and health care costs. All data were from 2017 and came from all 50 states and Washington, D.C.
 
Read full article in packet or at links provided
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Clay’s Weekly Medicaid RoundUp: Week of May 20th, 2019

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

For optimist readers- http://bit.ly/2VPQuk2

 

KNOW WHY YOU GET TO GRILL BURGERS ON MONDAY? Because brave soldiers died protecting you from threats home and abroad. Take a moment to learn about a few heroes who died recently- http://apps.washingtonpost.com/national/fallen/

 

OKIES DARING TO FOLLOW REGULATIONS AND CHECK ELIGIBILITY BY MAIL- In order to make sure the member rolls are accurate (sort of an important thing, especially in managed care states), CMS requires states to, you know, verify members exist. Part of that involves attempting to contact them. Attempting to contact them by mail is how CMS suggests to do it. Oh yeah- it also proves you live in the state (a term called “residency”). In the never-ending story of making it impossible to actually be a good steward with hundreds of billions of dollars, #Resisters in OK are ticked about a proposed rule to take bennies off rolls if the letters they send are returned undeliverable. Next year all it will take to get a Medicaid card will be to wish upon a unicorn’s left hoof and “poof” – you’re in!

CMS JOINS SPREAD PRICING FRACAS- Last week the Big House released guidance to states and plans about how to view spread pricing and MLR. The gist – it does impact MLR and any vig that an MCO paid to a PBM via spread pricing does NOT get to count as medical costs. Go figure.

LEARNING MORE ABOUT NC SDOH PILOTS- Key things you need to know: $650M will go to pilot programs for 50,000 bennies ($13k/each for Roundup Readers playing at home). Programs will address housing, transportation, food, and interpersonal violence. MCOs will manage the budgets for each benny in the pilots. RFPs for the Lead Pilot Entities (LPEs- the network builders) expected round about Thanksgiving.

BYE, MR. TRAYLOR- Chris Traylor, current head of the CMS Medicaid and CHIP services unit, will be stepping down on May 31. Calder Lynch (who did our state spotlight show a few years back) will be acting director.

 

BUT, YOU SEE, IT DOES FURTHER THE GOALS OF THE PROGRAM- When we’re not blowing money on people who don’t care enough to comply with paperwork, there’s more money to help the sick people on Medicaid waiting lists. At least that’s the argument being made in the Trump Team’s appeal of the work requirements lawsuits. Keep in mind the argument in the suit that slowed work requirements was that they did not further the goals of the Medicaid program. By showing how the new requirements do further the goals for the people who need it most, Team CMS has accomplished what in policy debate is known as a “Turn.”  Or maybe they’re obstructing some sort of Russian dossier under the emoluments clause of the 32nd amendment or something. Who knows? Rachel Maddow, that’s who.

 

ANOTHER OH MCO DROPS CVS- Buckeye Health dropped the drug giant this week. Caresource led the way a few weeks back.

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THE MEDICAID BLACK BOOK IS HERE- Want to know what’s on the mind of MCO CEOs? Want to see our in-depth reviews of vendors? Current issue is out. You can check it out here – http://www.mostlymedicaid.com/?product=medicaidblackbook

Companies reviewed in current issue:

  1. Apixio
  2. CareCentrix
  3. Digital Harbor
  4. HealthCrowd
  5. InComm
  6. Lucina Health
  7. Medical Advantage Group
  8. Moms Meals
  9. NowPow
  • Vheda Health

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FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award. Sort of a slow fraud week, so your chances of winning are higher. Hellen Kiago, of Sturbridge, MAH was convicted of stealing $2.5M from MA Medicaid. Her crime? She used her home health agency to bill for unnecessary services and falsified documents. Fun fact- once the coppers searched her office, she wired $1.5M to Kenya. Alejandro and Alexander Jiminez-Incera of Las Vegas were sentenced for stealing $3.7M from Care and Caid. They got caught because of a cash-for-opioids operation they were running, then investigators caught onto a bigger fraud where they were billing for patients they never saw.  Margaret Williams of Anchorage, AK was sentenced this week. In addition to getting one of her nursing home staff killed by having them work entirely alone amongst 5 residents with violent records, and not reporting the death within 8 hours, Maggie stole $1M from Medicaid by billing for services not provided. The Lifetime Movie is due out next week. Mrs Kiago – you win this week’s award for quick thinking in times of pressure. Taxpayers – shut up and smile while you watch your money go down the drain.

Need even more Medicaid fraud stories? – You can get your fix in the FWA Curator archives.

Want to read the articles summarized here, highlighted for your reading pleasure? Check out the News Curator archives.

 

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 (water and weed, water and weed) 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: Chúa Cha đã sai Chúa Con đến cứu thế gian.

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Monday Morning Medicaid Must Reads: May 20, 2019

Helping you consider differing viewpoints. Before it’s illegal.
other MMRS – http://bit.ly/2T7CP7K
In this issue…

Article 1:     Medicaid Demonstrations: Approvals of Major Changes Need Increased Transparency, GAO, 5/17/2019

Clay’s summary:    Now that Medicaid waiver requests are asking for something besides “more,” we may see an interest in actually doing the 1115 “demonstration” reviews.
Key Excerpts from the Article:
 About a third of Medicaid spending is for demonstrations, which allow states to test new approaches to delivering services. States and the federal government are supposed to be transparent about the demonstrations that are proposed and give the public a chance to weigh in. Is that happening?
The short answer is sometimes. Transparency has improved, but there are still significant gaps. For example, the federal government doesn’t always require states to share the projected effects of proposals, even when they could significantly affect beneficiary eligibility.
Read full article in packet or at links provided

Article 2:     The inconvenient truths of Louisiana’s Medicaid expansion, The Advertiser, Chris Jacobs, May 17, 2019

Clay’s summary:     All that “free” federal money? Federal funding still comes from taxpayers like you and me. And expansion may just be killing people on waiting lists.
Key Excerpts from the Article:
Second, the truly vulnerable continue to get overlooked due to Medicaid expansion. Secretary Gee claimed that her “top priority is to ensure every dollar spent [on Medicaid] goes towards providing health care to people who need it most.” But Louisiana still has tens of thousands of individuals with disabilities on waiting lists for home and community-based services—who are not getting the care they need, because Louisiana has focused on expanding Medicaid to the able-bodied.
Since Louisiana expanded Medicaid in July 2016, at least 5,534 Louisiana residents with disabilities have died—yes, died—while on waiting lists for Medicaid to care for their personal needs. Louisiana should have placed the needs of these vulnerable patients ahead of expanding coverage to able-bodied adults—tens of thousands of whom already had private health insurance and dropped that insurance to enroll in Medicaid expansion.
Read full article in packet or at links provided

Article 3:     Why Medicaid carriers are wary of joining the ACA marketplace, BenefitsPro, Scott Woolridge, May 13, 2019

Clay’s summary:     Making money on the exchanges is hard. Just stick with the safe bet of Medicaid capitation revenues, and invest in carving out hard stuff.
Key Excerpts from the Article:
 The analysis by the Robert Wood Johnson Foundation (RWJ) notes that in areas where Medicaid insurers compete with other carriers in the ACA individual market, premiums for that market tend to be lower overall. Of the 31 states that had Medicaid buy-in programs for at least some state residents, 18 states reported premiums that were priced lower than the national average.
“This suggests that convincing more Medicaid insurers to sell marketplace plans could lower marketplace premiums,” the report said. “Participating in marketplaces can benefit consumers as well as insurers: several large Medicaid insurers are turning a profit on marketplace plans. Yet many other Medicaid insurers have chosen not to sell marketplace plans.”
Read full article in packet or at links provided
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Clay’s Weekly Medicaid RoundUp: Week of May 6th, 2019

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2VnKiQ8

For optimist readers- http://bit.ly/2Vm4O3f

(Special Mother’s Day song selections)

YOU WILL ACCEPT MEDICAID WHETHER YOU LIKE IT OR NOT- Clark County (NV) passed an ordinance this week that requires any new ERs to take Medicaid (and Medicare). Magically, existing ERs / hospitals don’t have to comply.

HUMANA TO CENTENE: “IF THAT WELLCARE THING DOES’T WORK OUT, TAKE A CHANCE ON ME”- Hedge funds with important stakes in Centene have voiced second thoughts about the recently announced WellCare deal. Smelling opportunity, Humana has batted its doe-eyes at Centene. Centene shares up; WellCare shares down. More to come.

 

OK WE’RE GONNA START CHECKING INCOME FOR REALS, YALL- Louisiana reps are moving forward with a bill that will – wait for it- connect Medicaid eligibility systems to federal tax data to verify income eligibility. Where are all the kudos from the people telling me interoperable big data is the answer to everything? Can I get an Amen? The space-age tech comes on the heels of highly publicized news of LA having to kick 30k members off the rolls for earning too much money (some of them six figures). #Resist!

 

GROUNDHOG DAY: NORIDIAN WINS IOWA MMIS CONTRACT, AGAIN- Yet another snub to the whole modular / let’s shake things up and get some fresh blood in the MMIS world movement. Noridian (congrats, btw) won the Iowa MMIS contract again. It has held it since 2004.

 

FASTER WAIVERS- CMS approved waivers in 16% less time in 2018 compared to 2016. New reports coming out of Madame Verma’s office show that long overdue bureaucratic reforms are working. 78% of waivers are now approved within the first 90-day review period. And the backlog of pending state plan amendments is now down 80%.

 

LOOKING LIKE LIMITED EXPANSION WILL PAY AT SAME RATE AS FULL ACA EXPANSION, SUCKERS! –  I have sat through nearly a decade of obnoxious taunts from blue states to red states about being fools for not taking the awesome federal gravy train money deal for expansion. Seems like hold outs may have the last laugh- not only will they possibly get the same FMAP (90%) under a more responsible, limited expansion on their own terms – they also got to sit out of the spending orgy that got all those expansion states even more addicted to the federal teat from 2010 to 2016. CMS is saying its open to paying 90% of costs of “conservative” expansion plans like the ones being asked for in GA (that go up to 100% FPL vs 133/8). The Peach State plans to submit its waiver to CMS by the end of the year.

 

VOLUNTEER STATE MOVES FORWARD WITH BLOCK GRANTS; PEARLS CLUTCHED- State reps passed a bill that gets the governor to submit an 1115 to CMS to convert TennCare into a fixed-payment program (vs the open-ended, spend forever, drive-it-like-you-stole-it normal model). Similar to what Utah did in February. Other sources report that CMS is expecting more states to request a block-grant conversion, and the agency is drafting guidance on how to make the ask.

 

WE, LIKE, TOTALLY VOTED FOR THE SIMPLE EXPANSION, MAN! GIVE US THE SIMPLE ONE NOT THIS COMPLEX MEDICAID STUFF- You can’t blame voters in Nebraska for thinking the work in expanding Medicaid was done when they filled in their ballot bubble. Everything is oversimplified for the electorate, and healthcare is no exception. Problem is somebody must pay for what they thought they were ordering off the taxpayer menu. In their minds they were getting the Porterhouse for 100,000 of their newest Medicaid card-carrying friends. In reality there’s no budget for Porterhouse, so voters may end up ordering off the kids menu. What do you do when you don’t get what you want in modern America? Sue! And that’s of course where this is going… Resisters have already fired up the outrage machine and are threatening litigation.

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THE MEDICAID BLACK BOOK IS HERE- Want to know what’s on the mind of MCO CEOs? Want to see our in-depth reviews of vendors? Current issue is out. You can check it out here – http://www.mostlymedicaid.com/?product=medicaidblackbook

COME HANG OUT IN BALTO IN MAY– I’ll be speaking and generally gallivanting at the Medicaid Managed Care Congress May 20-22nd in Baltimore. Would love to see you there. Check out the event here- http://bit.ly/2ZsRcqd

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FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award (record scratch sound)- not so fast this week dear readers. I wrote too much above and need to land this plane.

Need even more Medicaid fraud stories? – You can get your fix in the FWA Curator archives.

Want to read the articles summarized here, highlighted for your reading pleasure? Check out the News Curator archives.

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 (thin things that are sprouting to the proper spacing- there’s info on that seed packet if you didn’t throw it away) 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: piyāṇan vahansē lōkayaṭa gaḷavannaṭa putrayā evū sēka

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Clay’s Weekly Medicaid RoundUp: Week of April 22nd, 2019

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

For optimist readers- http://bit.ly/2ULxAdG (absolutely incredible album, btw. If you ever find yourself driving all night, listen to this album all the way through)

THREE – COUNT EM’ – THREE PAYMENT MODELS FOR DUALS- Seems like we have some decisions being made on the results of all those FAI/duals demos. Last week CMS sent out a State Medicaid Director Letter pitching 3 options for covering duals moving forward. Option 1 is basically how the FAI demos worked – a 3-way contract with the federalis, an MCO and the state. Option 2 creates some weird thing where states and CMS “partner” to run fee for service programs for duals and share Medicare savings (you know, all those savings that fee for service is famous for). And Option 3 is a wildcard where states can cook something up not on the list. One thing I learned: less than 10 percent of duals are in a model that integrates Care/Caid services today.

SUNSHINE STATE STILL FIGURING OUT HOW TO PLEASE HOSPITAL BIGWIGS BUT LOOK LIKE THEY’RE NOT- Fiscal holdouts in FL have been trying to reduce Medicaid hospital spending by about 3%. That was the opening bid, anyway. Now lawmakers are saying maybe they won’t make the cut if they can get consensus on “resfhuffling” (that’s politician speak for “move the money to where the lobbyists tell me to”) $318M in Medicaid uncompensated care funds. Right now the fight hinges on whether to shell out the moola evenly to all hospitals (with an across the board up in base rates) or to distribute it based on who sees the most Medicaid patients (you know, the ones with the most uncompensated care). Problem is the ones who see the most are probably not the same ones sending lobbyists to the state house.

 

HANGING WITH MR. COOPER- Good Guvn’r Cooper of NC continues to hold a torch for expansion in the Tarheel State. If you look real close you can see him winking when he says “let’s talk expansion, then we’ll deal with details like work requirements.”

 

VOLUNTEER STATE EXPANDS MEDICAID FOR DISABLED KIDS, BUT ITS NOT THE TYPE OF MEDICAID EXPANSION LEFTIES WANT, SO CRICKETS- TN House Reps voted to use online shopping taxes to fund more services for more kids using the Katie Beckett waiver. Under their plan, $27M would go to help 3,000 kids with severe disabilities regardless of income. As of now the state Senate is not ok with the plan. So call moveon.org, or whatever your protest provider of choice is and make sure you get a flood of people with picket signs up in the TN statehouse.

 

$463M OVER BUDGET FOR MEDICAID, COOL. SPEND TINY AMOUNT TO CREATE NEW OFFICE TO GET SOME BETTER NUMBERS MOVING FORWARD? RESIST!!- Officials are still double-dog promising that the nearly half-a-billion overspend on Medicaid had nothing to do with expansion (they just happened to occur roughly at the same time). Even if that absurd claim were true, you would think a bill to establish an Office of Independent Medicaid Numbers (not the actual name, but you get it) would sail through. It did in the house, but not the senate. In case you need a reminder, taxpayer, your job is to pay, pay, pay. To ask for better oversight is downright Deplorable.

 

GOTSTA PAY BACK THAT CASH NURSING HOMES- Rhode Island fronted about $84M to nursing homes when they were working out problems with the application system. Now the loan has come due, but the nursing home lobby is saying they need more time (and they are suggetsing that the backlog might happen again). Loan repayments start in May, and they are supposed to pay most of it back by June 2020.

 

CONGRATS TO SOFTHEON IN WV- They just went live with their asset verification tool that integrates with the Medicaid eligibility system to check assets for Medicaid and SNAP applications. Out of 560,000 Medicaid bennies in WV, 350,000 also have SNAP so the overlap will help drive significant processing efficiencies for both programs.

 

KEYSTONE STATE CHECKING UNDER HOOD OF MEDICAID PROVIDERS- So this is new. The PA auditor general announced he will be randomly auditing Medicaid “contractors” (ie providers that are not docs) to make sure monies are not being wasted in the $33B program. Out of “thousands” of contractors, 6 will be in the first round of review.

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THE MEDICAID BLACK BOOK IS HERE- Want to know what’s on the mind of MCO CEOs? Want to see our in-depth reviews of vendors? Current issue is out. You can check it out here – http://www.mostlymedicaid.com/?product=medicaidblackbook

COME HANG OUT IN BALTO IN MAY– I’ll be speaking and generally gallivanting at the Medicaid Managed Care Congress May 20-22nd in Baltimore. Would love to see you there. Check out the event here- http://bit.ly/2ZsRcqd

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FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award. Jennifer Lynn Robinette of Gwinnett County, GA plead guilty to stealing $800K from residents of her Wishes 4 Me facility (housing people with physical and intellectual disabilities). She convinced them to open joint bank accounts and then took the cash. What’s the Medicaid connection? Ultimately the cash was from the GA Medicaid Independent Care Waiver Program. Move west on over to Baton Rouge, LA where we have a sizable member fraud. Naji and Shifa Abdelsalam failed to disclose their income from multimillion-dollar businesses and got about $74K in Medicaid benefits. Fun fact – one of the businesses they own is Five Star Medical, a Medicaid transport company. And – wait for it – they were stealing Medicaid bucks with that, too. Stick in LA for a moment more – Latoyia Porter of Covington, LA operated Walk With Me. Seems Walk With Me may have stolen more than $100K in Medicaid bucks by charging for counseling sessions that were not provided (or provided by underqualified staff). Now lets scoot on up to Maryland (but still below the Mason-Dixon line), where we find a case in which 5 cardiologists stole $81K by double-billing for similar procedures. In addition to testing for vein sufficiency (somebody with medical letters on their profile please comment what that means), they also billed for an older test for the same thing. Finally, let’s fly on over to Springfield, MO where we meet James Dye. Mr. Dye (technically Dr. Dye, which phonetically is much more ominous) was a dentist who stole $165k by billing $50 mouthguards as $700 “prosthetic devices.” Dr. Dye- you win on sheer hutzpah alone. Taxpayer, you know the drill.

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 (stare at the ground and watch seedling sprout, its good for the soul and better than checking email) 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: u yuum tu túuxtaj yaal le paal utia’al salvar yóok’ol kaabe’

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Clay’s Weekly Medicaid RoundUp: Week of April 15th, 2019

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

For optimist readers- http://bit.ly/2y9t7L7

MEDICAID PROGRAMS TO START COVERING CIGARETTES AS BENEFIT- Might as well, we’re still paying for all the results of Medicaid bennies smoking. New numbers out show we could save $2.6B if just 1% of Medicaid smokers quit.  On average states would save $25M (which is enough to put a dent in some of the state costs of expansion). To me this one is like fraud – do some fixin’ on it before you pass the hat for more, more, more, evermore tax dollars.

 

MCO MAKES GIANT LEAP FORWARD TO IMPROVE PBM PRICING ISSUES-  CareSource made big news when it dropped its PBM and decided to partner up with Express Scripts under a new contract. Even bigger was the news they decided to give the state of Ohio an unredacted copy of the contract, including all pricing info. You can’t get more transparent than that. Unless of course you’re some knucklehead journalist who somehow thinks not only state officials but all of the public should also have a copy of the contract. No good deed.

ROBERT MUELLER TO INVESTIGATE IOWA MCOS- He does have some time on his hands these days. Advocates in Iowa have been clamoring for years to get a special investigation into what they say is rampant service denial by MCOs. While the news stories are short on facts and long on mantras, you do have to wonder when you see things like the recent United exit.

KANSAS DECIDING WHETHER TO USE SURPLUS TO SPEND MORE ON MEDICAID HEALTHY ADULTS OR GIVE IT BACK TO THE PEOPLE PAYING FOR MEDICAID COSTS- Kansas tax revenues will be slightly less than 1% more than projected (must be this terrible economy), so lawmakers are doing their duty and figuring out what to do with the extra cash. The Good Guvn’r Kelly is softly messaging Tax Relief Bad, More Medicaid Good. Well maybe not so softly- she did veto a tax relief bill a few weeks back. Her numbers to pay for Medicaid expansion are around $34M net, so if she could maybe inspire 1% of Medicaid bennies to stop smoking, she could cover it (see lead article).

MONTANA EXPANSION FIGHT GETS INTERESTING- It has come down to straight up horse trading between saving coal jobs and expanding Medicaid. Maybe they need to review the tape of one our brightest luminaries to get some ideas.

MICHIGAN UNIVERSITY MAY BE TAKING TOO MUCH OF A CUT IN MEDICAID BUCKS FOR PROVIDERS’ LIKING- Best I can decipher of this one, it may be a UPL-type issue. Seems Wayne State University (Detroit) gets beau-coop Medicaid bucks in a draw-down meant to fund Medicaid services through its medical facilities. It then pays providers who perform those services. But turns out it may be keeping millions for itself as a middle-man fee. Which actually is entirely legal based on what I understand of the UPL (upper payment limit) regs. But that doesn’t mean it doesn’t make the docs ticked when they find out they were shorted millions from the overall pot.

WAIT- YOU MEAN WE HAVE TO PAY FOR MEDICAID EXPANSION? NOBODY SAID ANYTHING ABOUT PAYING FOR IT- Idaho lawmakers now have the enviable job of paying for what voters bought back in November. One of the leading ideas on how to pay for expansion is to assess counties a fee based on how many Medicaid eligibles there are in that county. Makes sense, right? Well class, remember, we are not a group focused on logic unless it fits our own agenda. In reality, more of anything (including the Magic Wand of Medicaid Cards) costs more, and there will be winners and losers. In Idaho, 21 counties will pay less and 23 will pay more. And the pot will likely be property tax, which of course disproportionately impacts property owners… Some of them are not exactly happy, and I would wager may not have been in the 61% that voted yes on More Medicaid. But they just need to suck it up, and if we vote it in, we can force you to pay. Democracy and all.

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THE MEDICAID BLACK BOOK IS HERE- Want to know what’s on the mind of MCO CEOs? Want to see our in-depth reviews of vendors? Current issue is out. You can check it out here – http://www.mostlymedicaid.com/?product=medicaidblackbook

COME HANG OUT IN CHICAGO END OF APRIL- I’ll be speaking / chairing the 4th Annual Medicaid Managed Care Leadership Summit, April 29-30th in Chicago. If you are interested in going, send me a note so we can coordinate, and I can also get you a 15% off registration. Check out the event here- http://bit.ly/2Hf1vYl

COME HANG OUT IN BALTO IN MAY– I’ll be speaking and generally gallivanting at the Medicaid Managed Care Congress May 20-22nd in Baltimore. Would love to see you there. Check out the event here- http://bit.ly/2ZsRcqd

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FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award- er, not so fast readers. Not enough space this week. Check out some oldies but goodies in the archives (links below).

Need even more Medicaid fraud stories? – You can get your fix in the FWA Curator archives.

Want to read the articles summarized here, highlighted for your reading pleasure? Check out the News Curator archives.

 

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 (plant 300 square feet of sunflowers- I did!) 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: piyāṇan vahansē lōkayaṭa gaḷavannaṭa putrayā evū sēka