Author: MM_ADMIN

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2U3uykk

For optimist readers- http://bit.ly/2U270we

IT WAS 50 FEET TALL AND CAME FROM ANOTHER PLANET! ATTACK OF THE GIANT MCO!! In case you haven’t heard, Centene is gobbling up WellCare for $17B. Will make them the biggest MCO in the universe. To be honest I was surprised- WellCare was doing well marching to the beat of its own drum (and I like that sort of thing). I am sure it will take a year to placate deal-reviewing bureaucrats, and probably another year before its really seen in market facing roles. And by then all MCOs will be sold to the new Walmart-Amazon-Costco conglomerate…

UHC IOWA EXIT- Not a lot of friends made by UHC on this one. UHC is filing for a divorce from Iowa Medicaid (more like just walking out and leaving the keys on the table by the door). There is a Dear John letter, though. You can read that here. Basically they blame the rates and go so far as to suggest a new way of doing the math. Surely it makes it a little easier on UHC to bail since AmeriHealth Caritas did it in October 2017- but I promise states don’t forget this type of thing.

WELL WE TOLD YOU THE NEW SYSTEM WAS GONNA FIX THOSE CRAZY BIG INELIGIBLE NUMBERS- Remember the stories of LA Medicaid paying like bazillions of Medicaid bucks for members who were not eligible? And remember that the answer was the tried and true “yeah, but the new thing is gonna fix it.” Looks like that was true. Louisiana’s new eligibility system dropped more than 30,000 people from the rolls this week. Almost all of them are non-elderly, non-disabled adults brought in under the Good Guvn’r Bel Edwards ginormous expansion in 2016. Secret sauce to the stronger, more accurate eligibility system in the Pelican State? It does quarterly checks (instead of sorta-kinda-maybe-annual ones) and uses more wage data to verify income.

ALASKA, IM GOTTA ASK YA– I totally did just make a rhyme with “Alaska”. How many times have you seen that in your life? (or heard that, I guess?). Well anyway, the thing I gotta ask ya, Alask-ya (its getting better by the sentence, isn’t it?) is – do you think you really will be the first state to convert your Medicaid program to a block grant? AK Good Guvn’r Dunleavy sent POTUS a letter asking for just that on March 1.

UTAH TO VOTERS- “WE DECIDED TO GO A DIFFERENT DIRECTION” – Seems conservative citizens aren’t the only ones who get screwed by their representatives. Lefty voters in Utah selected “lots more Medicaid at full ACA rates” on their ballots last year, but instead are getting a good bit more Medicaid, at 100% FPL levels. This could be the first “limited expansion” we keep hearing about, and that Verma is now letting us know CMS could be open to. (See also stories about the GA request).

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THE MEDICAID BLACK BOOK IS COMING- Want to know what’s on the mind of MCO CEOs? Want to see our in-depth reviews of vendors? Next issue comes out 4/15. You can see our latest explainer video for it here – http://www.mostlymedicaid.com/?product=medicaidblackbook

COME HANG OUT IN CHICAGO END OF APRIL- I’ll be speaking / chairing the 4^th Annual Medicaid Managed Care Leadership Summit, April 29-30^th 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

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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. Frank and Melanie Palcic of Pueblo, CO stole about $1M using their speech therapy service to submit bogus claims. Kevin Schaul of Springfield, MO was sentenced for his pilfery totaling $600k. How did he do it? False claims to Medicaid for incontinence products. Liem Do and wife Phuong Tran of Clark County, WA were ordered to pay $1M back to Medicaid for a long list of dental frauds. Looking for a good early summer fraud trial to watch? Head down to Miami, where Philip Esformes is on trial for a $1B Medicare and Medicaid fraud. Mr. Esformes is charged in a gigantic kickback scheme related to his network of assisted living facilities. This story even has a sub-plot about him paying a university to let his kid in, so you can get some of that good buzz from the current celebrity college fraud scandal, too. Mr. Esformes is fighting it though, so the drama will be high. One thing cool from this story- I learned that its so bad in Miami now, the city has actually become known as the “healthcare fraud capital in America.” Jeffrey Terry of Mangum, OK was indicted this week for using his pharmacy to steal $1M (from both Care and Caid). What did he do? Submitted phony claims for drugs that were never prescribed to patients. And finally, we come to Rose Presser of Milwaukee. Rose used her mental health clinic to steal $4.1M from Medicaid by running unnecessary urine tests through her substance abuse treatment program. So, if you were ever wondering if you can literally p*ss away $4.1M – you can. This week’s award goes to husband and wife team The Palcics. I just love a good love story, don’t you?

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 (prepare garden beds; it won’t be long and we can plant!) 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: UBawo wathumela uNyana ukuba alondoloze ihlabathi

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

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

OPIOID COURSE GETTING RAVE REVIEWS-– Want to understand the opioid crisis? Our newest online course will help. Check it out here- http://bit.ly/2WEL3G4

COME HANG OUT IN CHICAGO END OF APRIL- I’ll be speaking / chairing the 4^th Annual Medicaid Managed Care Leadership Summit, April 29-30^th 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

HMM, NOT SURE YOU REALLY UNDERSTAND THE PROBLEM MS. LIGHTFORD- Gifted health policy expert (and Democratic Illinois Senate Majority leader Kimberly Lightford) took to lambasting MCOs this week for “threatening the very future of our health care providers and the patients they serve all around this state.” Their crime? According to Lightford, excessive claims denials that are coming in around 26% (MCOs say its less than 11%). Compared to the 1-2% denial rate (aka as total failure to manage costs and just pay freakin everything) before the state implemented managed care, 11% suggests maybe there are at least a few more controls in place. But the real root cause – just maybe- is that the state of Illinois has been in default to the tune of billions to MCOs multiple times over the past several years. Hopefully the MCOs won’t get caught holding the bag for the dumpster fire that is Illinois state budget “management.”

IOWA WORK REQUIREMENTS BILL MOVES FORWARD- Would likely apply to the 172k members added as part of ACA, but if it goes like any of the rest of them have the vast majority will be exempt from the requirements.

TX SETTLEMENT WITH XEROX MAY ACTUALLY END UP COSTING LONESTAR STATE MORE THAN THE PAYOUT- Turns out when you pay the feds back their $133M (it is mostly federali money that states blow, remember?), and the whistleblowers (who may get $50M or so) and the attorneys, that $236M payout dwindles down pretty low. Clearly, its just not worth it to fight fraud, waste or abuse in Medicaid. Can we just pay everybody what they ask and move on to saving the world, please?

PROVIDERS NOT HAPPY TO BE MAKING LESS MONEY IN NY- Cuomo can’t seem to make up his mind. A few weeks back he was taking off some spending restrictions (the one where Medicaid payments have to come in under a healthcare inflation index), but this week he’s talking about taking $567M out of the Medicaid budget. And providers (mostly nursing homes and ambulance moguls) are ticked. If you haven’t ever worked closely with the ambulance lobby, you are not familiar with how dramatic they can be when their billing codes are under fire. According to the NY ambulance lobby, the proposed rate cuts create an “impending collapse of the statewide ambulance industry.” Uber for EMS, anyone?

KANSAS QUANTIFIES COSTS OF EXPANSION- Depending on if you believe the “Medicaid expansion as economic stimulus” argument, KS economists are pricing expansion somewhere between $520M to $1B over 10 years. Year 1 will have lawmakers passing the hat for about $47M more to cover expansion.

MAINE OPENS NEW CALL CENTER TO DEAL WITH EXPANSION APPLICATION VOLUME- Western Mainers will notice a new call center opening up this week to house 45 call reps. There are about $1M in new outreach costs for the recently passed expansion. Timing is good – Barclay’s is closing a call center end of this month, so at least some of the 200 people getting laid off there will be able to slide on over to the new Caid Call Center. That will be an interesting switch in scripts for the reps… going from “Hi, I’m calling about your Barclay’s card..” to “Hi, I’m calling about your Medicaid card..”

SHOW ME STATE CONSIDERING CHANGE TO POLICY ON PAYING FOR MEDICAID FOR INMATES- While many of you who work the Caid/criminal justice overlaps already know about the benefits of changing policy to just suspend Clay’s caid benefits when he goes in the slammer (vs terminating them), MO is clue-ing into this. It makes it easier to turn the benefits back on (and off and on and off depending on the recidivism profile of the bennie) once Clay gets back out. And it could help him stay free if it means he gets opioid treatment, help finding a job or various other things Medicaid is evolving to provide.

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. Everado Villareal and Delilah Robles of Mcallen, TX got charged with stealing $850K in TX Medicaid bucks. Their crime? A DME scheme in which they paid a partner to steal Medicaid bennie IDs so they could submit bogus claims for incontinence supplies. Eliza James of Lansing, MI stole $200k using her role as a state HHS worker. She would refer Medicaid members to providers she knew and then approve services for the members. Then the providers would deposit money in her account (so a basic kickback scheme). Steven Baraban of Kansas City stole $9.5M using a scam in which he got paid by MO Medicaid for pain creams and antibiotics that never made their way to members. A whistleblower got $1.5M on this one, by the way. Sort of a slow fraud week, but some interesting small time benny frauds in the Curator if you want to check them out. Mr. Baraban, you are the clear winner! Congratulations!

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 (prepare garden beds; it won’t be long and we can plant!) 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: uBaba wathumela iNdodana ukusindisa umhlaba

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2SgkS5m

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

NEW ONLINE TRAINING COURSE IS OUT– Want to understand the opioid crisis? Our newest online course will help. Check it out here- http://bit.ly/2WEL3G4

YES, DOROTHY, WE ARE STILL IN KANSAS AND WE ARE STILL WAITING ON OUR MEDICAID APP TO BE PROCESSED AFTER STANDING IN LINE FOR 2 YEARS- A lot of the eligibility processing backlog has been handled, but there are still issues. New stories out this week give more depth to the issue, and it does look like Maximus (the eligibility processing vendor) doesn’t share all the time. But they are in over their heads. The SNAFU seems to have started when the vendor took on a new (to them) type of eligibility determination, related to long term care members. They had done the much more simple apps for kids and families for 20 years. There’s a really good article on this in this week’s News Curator, btw.

REASON #472 TO EXPAND MEDICAID: IT MAKES HOSPITALS EVEN RICHER- TransUnion Healthcare (a credit reporting agency trying to grow up into a broader info services role) released a report this week showing that Medicaid expansion can help add millions to hospital bottom lines (see this week’s soundtrack for a related song). The researchers reviewed thousands of cost reports to identify self-pay bad debts that could be covered by Medicaid if a state expanded.

QUESTION TO ALL THOSE #RESISTERS AGAINST WORK REQUIREMENTS- You keep talking about how hard it is for members to comply with reporting. Are you thus volunteering to make it easier in some way? Or are you really just continuing to beat your gums about how you think work requirements are just bad? Say what you mean, footsoldiers. Multiple regurgitated stories this week about how hard it is to call in, log on or in various other ways report that you tried to work if you were able to in Arkansas. I think Resisters know they lose the argument on whether its fair to ask those that can work to work, so they incessantly talk about challenges with reporting compliance. Yes, its hard. So roll up your sleeves and help out. Here’s an idea – ACA had gabillions in funding for “navigators” to help people sign up for coverage. Maybe repurpose those same staff to help people prove they are eligible to keep it?

TARHEEL GOOD GUVN’R TEASES EXPANSION- Cooper is now doing townhalls / expansion “roundtables” as of this week.

PINE TREE STATE EXPANSION TICKING AWAY NOW THAT LEPAGE IS OUT OF THE WAY- 6,000 bennies added to the Maine rolls since January.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Anita Ramiriz-Ambriz of McAllen, TX was convicted of stealing $4M Medicaid bucks almost 2 years ago, but yet again was able to delay sentencing this week (pro-tip for convicted fraudsters in here somewhere). Her crime? Getting paid for DME not provided. Head on up to Plattsburgh, NY for our next caper, in which Arshad Nazir and Muhammad Jahangir were convicted of Medicaid taxi-cab fraud (isn’t it great that this is a thing? Its become its own category in recent years). Messieurs Nazir and Jahangir pilfered a combined total of $567k by operating a kickback scheme. Medicaid patients were paid (often times with a bag of tobacco) to say they needed to get somewhere related to their health condition. The taxi companies then would get $230 (or so) for a “non emergency medical transportation ride.” Taxpayers, we truly are gullible fools. Skip on down to Durham, NC to check out Tamara McCaffity’s scheme. She was sentenced this week for stealing $900k using her mental health provider companies (one of them DBA “Dreamworks II,” which frankly is a great name. We should maybe start a new award category for best named bogus mental health provider companies. There have been some doozies over the years). McCaffity bought stolen Medicaid member IDs so she could submit bogus claims to Medicaid. And you, dear taxpayer, paid them (if you live in NC, you only paid about 30%. If you are outside of NC, you paid about 70% through the FMAP. See that whole “but its free federal money” silly argument goes both ways). Mrs. Ramiriz-Ambriz- you win this week’s award on technique alone. I am truly impressed that you have avoided sentencing for 2 years despite being convicted of Medicaid fraud. (Why do we even try to fight this stuff?)

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 asparagus – did you know it takes 2 years?) 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: Ntate o rometse Mora ho pholosa lefats’e.