Author: MM_ADMIN

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Clay’s Weekly Medicaid RoundUp: Week of December 3rd, 2018

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2B0dxAj

 

For optimist readers- http://bit.ly/2B596nU

 

MAINERS GETTING MORE MEDICAID FEB 1- After a long battle against Medicaid expansion (which gave us a lot to cover for years), LePage may have finally lost. A judge ruled the voter-approved expansion must go forward. LePage will be gone (doing whatever Mainers do when they retire and its winter, I guess. Something in a cabin?), and the new Good Guvn’r Janet Mills will come in Jan. 2, with magic wands, puppy dogs, unicorns and Medicaid expansion promises.

 

NEW HAMPSHIRE WORK REQUIREMENTS STILL ON- Seems CMS still gets to decide which parts of requests it does / doesn’t approve. CMS approved NH’s work requirements waiver (basically as a trade-off to let them keep expansion). CMS did not approve a provision that would allow seasonal workers a different way to add up their hours to reflect the surges in employment they have during certain times of the year.

 

FLORIDIAN BENNIES NOW HAVE ONLY 30 DAYS TO FILE PAPERWORK- Several states have requested the option to reduce retro-active eligibility from 3 months down to 1. Florida got approval for this and the change will go into effect Feb 1. Officials estimate it will save the state $98M (women and children are exempt and still have 90 days). Other states with recent approvals for the same request include IA and KY.

 

PELICAN STATE PAYING MILLIONS FOR INELIGIBLES – Louisiana spent at least $60M and as much as $85M on bennies who were not eligible, according to an auditor’s new report. The system to confirm self-reported income was not effective at getting info about changes in income.

 

FORTUNE SEEKERS GO TO COURT- Did you know that’s one of the demonyms of Idahoans? A taxpayer-rights advocacy group is suing to stop the Medicaid expansion voted in by 60% of voters in November. According to the lawsuit, letting voters decide these types of things is “A sweeping and general delegation of legislative power with uncontrolled, unrestricted or unguided discretionary power [that] exceeds constitutional limits…”

 

MINIMUM WAGE HIKE IN JERSEY TRIGGERS $200M MORE IN MEDICAID SPEND- When you raise the wage for everyone, that includes Medicaid home health workers.

 

CALIFORNIA TO SPEND $3B ANNUALLY TO GIVE ILLEGAL IMMIGRANTS MEDICAID COVERAGE- A bill from last year is expected to get re-introduced in the next session. Would add about 1.2M people to the rolls.

 

 

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. Erik Dewayne Lean of Greensboro, NC was sentenced to 18 months for stealing $420k in a kickback scheme for his counseling business. Rajendra Bothra (of Detroit) and 4 of his buds were charged this week for stealing $500M from Medicare and Medicaid (so ineligible for this week’s award, but notable). How, you ask? By prescribing more than 13M doses of opioids. Based on initial reports, this could come close to some of the FL pill mill scandals from 10 years ago. Samuel Okere of Oklahoma City was sentenced to 1 year in federali lockup for stealing $141k in Medicaid counseling bucks (services not provided). John Ndunguru of Fairfax, VA has been charged with using his home health company to steal $4.5M from Medicaid. Mr. Ndunguru made submitted false Medicaid claims for patients not approved for long term care services. Still in VA (but now in Charlottesvile- about a 1hr 51 min drive south west from our last story), husband and wife team Dennis and Cheryl Gowin stole $210k from Medicaid by not disclosing that Dennis had a felony conviction (which would have made him not eligible as a Medicaid provider, or even become a licensed counselor in VA). Anil Desai of Hotlanta has agreed to pay back the $213k he stole from Care and Caid by getting paid for drugs they never provided to patients. Tara Rose of El Paso, TX plead guilty to stealing $1M from Medicaid using her speech therapy business (“Beyond Words”) to bill for imaginary patients and services that never happened. Faiz Ahmed of Houston, TX was sentenced to 5 years in prison for stealing $4.1M by ordering unnecessary tests. There’s actually more this week, dear readers. I am just tired of typing.. This week’s winner- Mr. Ndungura of Fairfax, VA! Taxpayers, you lost at least $510M in the last paragraph.

 

 

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 (finish up your Christmas shopping? We do all ours online) 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 .

Want the Curator News Pack for this week’s Roundup? Medicaid News Curator Volume 3

Here’s the one for the Fraud stff- Medicaid FWA Curator- Vol 4

Trystero: el Padre envió al Hijo para salvar el mundo.

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Medicaid Job Hunter: 11/19/2018

We scour the internets for Medicaid jobs listings to save you time.

In this packet…
  1. Professional Healthcare Resources, Inc. Home Health Visits/Medicaid RN/Personal Care Registered Nurse in Washington, DC at Professional Health Care Resources Job in Washington, DC
  2. Population Health Specialist – Kentucky Medicaid Health Plan (54629BR) at Aetna
  3. New Career Opportunity! Medix has an opening for a Medicaid Biller in Burr Ridge, IL.
  4. Medicaid Eligibility Advisor
  5. Home Health Visits/Medicaid RN/Personal Care Registered Nurse
  6. Behavioral Care Coordinator at Centene Corporation
  7. Supervisory Health Insurance Specialist | Centers for Medicare & Medicaid Services
  8. Medical Director PRN – Medicaid Review | Qlarant
  9. Medicaid Health Systems Administrator 1 | Ohio Department of Administrative Services
  10. Grants Management Specialist. | Centers for Medicare & Medicaid Services

2018 11 19- Medicaid Jobs Hunter

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Monday Morning Medicaid Must Reads: Nov 19th, 2018

Helping you consider differing viewpoints. Before it’s illegal.
In this issue…

Article 1: COUNTERPOINT: Medicaid expansion is unfunded, unsustainable for state of Nebraska

Clay’s summary: Voters didn’t listen to this dude.
Key Excerpts from the Article:  …It is also likely that expansion costs will far exceed projections, just as costs have in nearly every state that has expanded. Iowa spent over $150 million more than expected. Kentucky’s Medicaid program is facing a $296 million budget shortfall due to unpredictable costs (yes, the program itself is that much in debt). Ohio’s Medicaid program costs the state an average of $437 million a month…
Read full article in packet or at links provided

Article 2: Maryland might not have properly vetted some Medicaid enrollees

Clay’s summary: Perhaps there was maybe some payments that could have been somewhat non-compliant with the law but who’s to say, really? It’s a gray area- move along.
Key Excerpts from the Article: Maryland may have allowed residents who did not qualify for Medicaid into the government health program for the poor by failing to consider all of their income, according to a routine audit of the quasi-governmental agency that oversees the Maryland health exchange.
Read full article in packet or at links provided

Article 3: Virginia facing high unexpected Medicaid costs

Clay’s summary: Well at least they decided to expand and spend even more (this is all costs not-related to recent expansion largess).
Key Excerpts from the Article:
State officials said Friday that Virginia has about $460 million in unforeseen Medicaid costs. …The new costs, first reported by the Richmond Times-Dispatch, are unrelated to Virginia’s recent decision to expand Medicaid eligibility to low-income adults under the Affordable Care Act. …Instead, Secretary of Finance Aubrey Layne said much of the new costs stem from faulty forecasts overestimating the benefits of having private health insurers cover a greater number of some of the state’s more costly Medicaid recipients. Another reason for the increase is a higher-than-expected enrollment of children in the state’s Medicaid program, he said…
Read full article in packet or at links provided
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Clay’s Weekly Medicaid RoundUp: Week of November 12th, 2018

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

 

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

 

MEGA RULE MUTATES- After a loooooong windup and much speculation, CMS finally showed its cards on possible changes to the Mega Rule. (Do you get the feeling they wait until early November for big stories just to make sure there are interesting convos in the NAMD hotel happy hours?) Highlights: Possible relief on cert for all those rate cells (may go back to ranges), 3 years to put on your big-boy pants related to pass-through payments, and more grace on using telehealth to meet network standards. And oh yeah – some stuff about making sure all you turkeys stop using different rate cells to game the federal match.

 

IL CRIES UNCLE- Following many other states (who are following judge’s orders in their own states), the Land of Lincoln (R-IL) has decided to open the floodgates on Hep-C coverage. Now no signs of disease or proof of sobriety are required to get the pills that cost about the same as a souped-up Civic. But hey- it used to be a new Vette.

 

MICHIGAN GETS TREATED LIKE AN ADULT- Add a W to the win column in the “restore a modicum of power back to the states game.” CMS approved Michigan’s request to negotiate their own deals for pricy drugs based on whether they actually work for the patient. This CMS approval comes 4 months after a similar gig for OK and a denial for MA. Right now the MI deal is focused on 4 drugs. I’m sure the list will expand, and if you say the magic words – “value-based-care,” “population health,” and“big data,” – four times fast, under a fool moon, wearing green slippers, the list of the next 4 drugs will magically appear in your left hand (if you’re left handed; else, your right hand).

 

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. Idris Talib of Columbia, SC got five years in the slammer for stealing $400k using false claims for counseling. Head on up 1 state to NC, where we meet Renee Borunda, who managed to steal $225K using another therapist’s billing ID for Medicaid claims that didn’t happen. Keep heading north until we get to Niagara Falls, NY (cool place if you haven’t ever visited), and we learn about Sadat Khan who used Wego Taxi Tours to steal $50k from Medicaid. How did he do it you ask? By falsifying pickup location addresses so the trips would appear longer and get more mileage reimbursement. Lets drop down to the paradise known as Detroit for our next shining light of Medicaid fraud- Jacklyn Price. Ms. Price and buddies stole $8.9M from Medicare (so can’t win today, sorry!) using a home health scheme. Over in Brooklyn, Yvette Juarez was picked up on a pretty decent-sized member fraud. She made too much money from her daycare business to be eligible for Medicaid, but falsified income statements in order to get about $72k in benefits. Now on to PA- 4 people operating “Moriarty Consultants” stole as much as $87M from Medicaid by fabricating personal care services claims. It gets good, in addition to boring stuff like faking timesheets, they made up employees and paid kickbacks to bennies to help pull it off (remember, fraud is most effective when you work as a team). Team Moriarty – you win! Your creativity and volume put you over the top; you do not live up to your namesake, however.

Taxpayer tab for this paragraph – about $96M. Work harder- and don’t complain or have bad thoughts about it, or else you’re a meanie!

 

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 (enjoy the early winter: apparently there are less sun spots right now?) 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 .

 

Want the Curator News Pack for this week’s Roundup? Medicaid News Curator Volume 2

Here’s the one for the fraud stuff

 

Trystero: Oče je poslal Sina, da reši svet.

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Medicaid Job Hunter: 11/12/2018

We scour the internets for Medicaid jobs listings to save you time.

In this packet –

  1. Healthcare Insurance Coordinator | Fresenius Medical Care North America
  2. Senior Government Health Plan/Managed Care Financial Consultant at Marsh & McLennan Companies
  3. Medicaid Health Systems Administrator 2 | State of Ohio
  4. Medicaid Compliance Dir-Plan PS14343 – Seattle with Anthem
  5. Insurance Reimbursement Lead – Medicaid & Government Billing – Maitland Job at Florida Hospital
  6. State of Florida MEDICAL HEALTH CARE PROGRAM ANALYST Job in Tallahassee, FL
  7. Program Manager – Arizona Medicaid – Phoenix, AZ
  8. Neighborhood Health Plan of RI Vice President Medicare/Medicaid Integration Job in Smithfield, RI
  9. Manager, Medicaid Case Management | Evolent Health
  10. PacificSource Health Plans Actuarial Analyst – Medicare/Medicaid Job in Springfield, OR

2018 11 12- Medicaid Jobs Hunter

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Monday Morning Medicaid Must Reads: Nov 12th, 2018

Helping you consider differing viewpoints. Before it’s illegal.
 
In this issue…
Article 1:

MACPAC urges Azar to pause, re-evaluate Arkansas’ Medicaid work requirements, Eli Richman, FierceHealthcare, Nov 9, 2018

Clay’s summary:
MACPAC feels left out with all the attention on work requirements, needed to go on record as raising yellow flag.
Key Excerpts from the Article:
In a letter to Department of Health and Human Services (HHS) Secretary Alex Azar, the independent commission that advises CMS on policy matters said it was “highly concerned” about the statistics and recommended the state pause the program until adjustments can be made… The disenrolled individuals in Arkansas were unable to report work and community engagement activities as required by the policy, but the commission argued that the state’s approach contributed to the challenges. However, MACPAC cited extremely low rates of successful reporting: A whopping 91.6% of the beneficiaries required to report compliance failed to do so in September 2018…. “The low level of reporting is a strong warning signal that the current process may not be structured in a way that provides individuals an opportunity to succeed, with high stakes for beneficiaries who fail,”
Read full article in packet or at links provided
 
Article 2:

Medicaid Expansion Opponent Picked to Lead Medicaid, Steven Porter, Health Leaders Media, Oct 16, 2018

 
Clay’s summary:
The current CMS/Trump administration has repeatedly expressed a clear belief that CMS can leverage Medicaid to alleviate poverty vis a vis work requirements being asked for by states. Lefties keep repeating the same rebuttals (and effectively calling Ms. Verma a liar when she refutes leftist claims that work requirements’ main goal is to reduce Medicaid rolls), and have not offered any other solutions to alleviate poverty. In the lefty mind, CMS really only pays for things and does not have any other function. In a shocking turn of events, the current CMS/Trump administration (duly elected by American voters, despite what tin-foil hat wearing loony left zombies think re RussiaHoax) has appointed someone who has a history of not floating the pay-for-everything Medicaid mainstream. If your head did not explode from this paragraph- quick, go knit another protest hat to deal with the trauma of someone disagreeing with you!
Key Excerpts from the Article:
Mary Mayhew’s rise-out-of-poverty rhetoric around Medicaid policymaking aligns with statements made by Trump administration officials. Mayhew oversaw a shrinking state Medicaid program and opposed Medicaid expansion… One critic, a Democrat, described her as “antagonistic toward Medicaid.” …A former hospital lobbyist who spent most of the past decade as Maine’s health commissioner under Gov. Paul LePage has been tapped to lead Medicaid on the federal level. …Mary Mayhew earned a reputation in Maine as someone who, alongside LePage, championed additional limits on the public benefit programs she oversaw, reducing enrollment in the state’s Medicaid program by 67,000 beneficiaries between 2011 and 2015 then opposing Medicaid expansion under the Affordable Care Act….
Read full article in packet or at links provided
Article 3:

Wisconsin Wins Federal Approval for Medicaid Work Requirements, Steven Porter, Health Leaders Media, Oct 31, 2018

Clay’s summary:
But, but, but- muh lawsuit!!!
Key Excerpts from the Article:
 
The state is the fifth to secure approval for such a program, but a federal judge blocked Kentucky’s waiver last summer, so Wisconsin is the fourth with an active waiver.
The federal government formally approved Wisconsin’s plan Wednesday to impose work requirements on certain Medicaid recipients, signaling that the Trump administration is not backing down from the controversial policy position.
Read full article in packet or at links provided
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Medicaid Fraud, Waste and Abuse Curator: Volume 2

From stories collected week of Nov 5, 2018

Total this week: $150M

 

In this issue..

Medicaid FWA Curator- Vol 2

Georgia Resident Indicted for Medicaid Fraud

The Office of the Attorney General has announced that Adrian Mance entered a guilty plea to one count of Medicaid Fraud on October 30. A Hall County Judge sentenced Ms. Mance to serve 10 years of probation and pay restitution in the amount…

 

UPDATE: Indiana Dental Practice & DSO Shell Out $5.1 Million Over Medicaid False Claims Allegations

Indiana-based ImmediaDent and DSO Samson Dental Partners of Kansas have agreed to pay the federal government and Indiana some $5.139 million to resolve false claims allegations of Medicaid fraud…

 

4 Charged in $87M Home Health Care Scheme

DOJ also announced recently that four Pennsylvania residents were charged in federal court with conspiracy to defraud the Pennsylvania Medicaid program of tens of millions of dollars. Pittsburg residents Travis Moriarty, 37, Tiffhany Covington, 41, Autumn Brown, 31, and Brenda Lowry Horton, 48, were charged in separate but related criminal informations with one count of conspiracy to commit health care fraud…

And much, much more!

 

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Clay’s Weekly Medicaid RoundUp: Week of November 5th, 2018

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2SVN6DU

 

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

 

VOTERS DECIDED TO GROW MEDICAID IN 3 STATES; SHOT IT DOWN IN 1- Idaho, Nebraska, and Utah all decided to “cover” more people with Medicaid (and to spend more money from the pockets of the people who voted against it (40% against in Idaho, 47% against in Nebraska, and 46% against in Utah). But hey – screw those guys! We voted yes, and now they have to pay for it. Losers buy!. 

IN RELATED NEWS, VA IS SHORT $460M IN ITS MEDICAID BUDGET- Sort of related, anyway. These are “unforeseen” costs that occurred before the expansion decision. I wonder if they would have disclosed these costs before the expansion decision, would that have impacted the expansion decision? Current theories as to the overage are higher costs under managed care than expected, and higher than expected CHIP enrollment. Most legislators in the state are already messaging that school spending in next year’s budget will have to go down to pay for this whoopsie.

 

MORE CONSOLIDATION IN THE IL MCO MARKET- Harmony and Meridian health plans are merging after the recent WellCare acquisition of Meridian for $2.5B. Harmony was struggling and was dinged back in May for having insufficient network.

 

CMS WORKING ON NEW RULE FOR STATE FLEXIBILITY ON NEMT- According to a notice of proposed rulemaking last week, CMS is cooking up a new reg that will give states some relief on how much they have to spend on non-medical transportation for Medicaid bennies (states have been asking for this for years, with AZ being the most current example I am aware of).

 

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. Get out your wallets taxpayers – we have some Medicaid fraud to pay for! ImmediaDent (a dental provider with a weird name) and Samson Dental Partners of KS have settled false claims allegations with three states (KY, IN and OH- I guess they didn’t want to fraudulate in their own state?) for $5M. What did they do? Billed simple extractions as surgical procedures, billed scale and root planings that never happened and put dental employees on volume-based commission plans. Sophia Eggleston of Detroit was convicted this week for her role in an $1M home health fraud scheme hitting the Medicare coffers. Travis Moriarity of Pittsurgh (and 3 of his buddies) were charged with defrauding PA Medicaid out of $87M this week. How did they rack up such a bigly fraud, you ask? With bogus claims for personal care services, care coordination and NEMT. If you want to hit the Medicaid fraud big leagues, you’ve got to diversify, people! Bernard Oppong of Blacklick, OH was charged with a pharmacy scheme. Oppong would partner with a pharmacy to send special medical crème to Medicaid members without ever examining them. So far all I have is that this is a “multi-million dollar” fraud… Pretty big whopper of a hospice fraud concluded this week when Patricia Armstrong of Coppell, TX plead guilty to her role in the $60M scam. Armstrong and others stole from Medicare and Medicaid by signing up bennies who didn’t need hospice and then billing for it. They forged terminal-illness certifications. Celestine “Tony” Okwilagwe, et al of Garland, TX were convicted for stealing $3.7M from Medicare and Medicaid using a home health scam. Bonus points- they were already barred from participating in any federal healthcare program. Jennifer Gardner of Summit Township, PA got $104k in member/provider fraud bucks illegally. Let me unpack this one: Ms. Gardner had one of these deals where Medicaid gives you cash to pay your own personal caretaker in your home. But her attendant moved away, she didn’t replace him and kept cashing the checks. Ms. Gardner, you win! You gave us a great illustration of the clear risks of this model! Thank you. Taxpayers, you lost about $159M in this last paragraph.

 

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 (do the first round of leaf-raking) 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 .

Want the Curator News Pack for this week’s Roundup? Here you go- Medicaid News Curator Volume 1

Here’s the one for the fraud stuff

Trystero: Otec poslal Syna, aby zachránil svet.