Author: MM_ADMIN

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Weekly Medicaid RoundUp: Week of July 31st, 2017

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

For optimist readers-  http://bit.ly/2vyM3kT

 

MONDAY’S STATE MEDICAID SPOTLIGHT SHOW FEATURES PRESTON CODY, DIRECTOR OF WA MEDICAID PROGRAM INTEGRITY- After a long break, our State Spotlight show is back. Sign up free here if you are not already – http://www.mostlymedicaid.com/?page_id=1739

YOUR MEDICAID DRIVER IS 3 MINUTES AWAY- The Greater Buffalo ACO has inked a deal with Lfyt to carry bennies to their appointments. NET is a big, fat, tempting budget item that a small set of providers have had to themselves for years. I am amazed it took this long to “disrupt” this “market.”

PREZ USES BROAD DISCRETION BUILT INTO ACA AND HEALTHCARE POOH-BAHS CLUTCH PEARLS- Just kidding. Trump’s not doing crazy things allowed in ACA like suspending the individual or employer mandate during an election cycle (what kind of cynical, Machiavellian tyrant would do stuff like that?). In all fairness the whole CSR payments drama is a perfect analogue to the abuse of power that was set up nicely in ACA. He does really have them by the яйца (yaytsa if your pc doesn’t have the right font installed), doesn’t’ he? CMS is also encouraging states to submit waivers to alter the eligibility conditions (i.e. all the work requirements waivers you’ve been hearing about) and in some cases the benefit packages (ex: Iowa got approval to limit NET). #Resist!

UPDATE ON MA EMPLOYER FEE FOR MEDICAID- Covered this last week. Seems the outrage was less about forcing employers to cough up $750 per employee on Caid and more about daring to tie that to an expected effort to reduce spending. The Good Guvn’r has repented of this sin and now the deal simply taxes employers (a total $200M in new fees) and does not dare attempt the evil, hateful- dare I say it, Republican? – cuts (would have been $150M in Medicaid spending cuts tied to the tax). Forgot Draconian. APA style manual says you must use “draconian” when talking about Medicaid cuts.

THREE NEW STUDIES OUT ON MEDICAID AND KIDS- Good sumhttps://woocommerce.com/my-account/tickets/?id=605141mary at the AAP blog – http://bit.ly/2wruJLd . One looks at Caid costs by level of illness and concludes that a full 1/3 of all costs are for kids with chronic disease. The other 2 look at child ER super users and Rx costs.

 

CLEVELAND CLINIC ON THE REBOUND AFTER GETTING DUMPED- Seems CareSource OH ditched Cleveland Clinic from the network recently and it stung. So now CC has started dating Molina- this is the first time CC has been in network for Molina. CareSource and CC have said they will cement the break up if no agreement can be reached until Sept 1.

IF YOU LIKE YOUR MEDICAID INSURANCE, YOU CAN KEEP YOUR MEDICAID INSURANCE- A recent national survey found that Medicaid members gave their plans 78 more points than commercial members (out of a total of 1,000 points- 0.078% diff). So, when its free, its less than 1% more popular than something that costs an average of $5k + OOP when you do pay for it for a family of 4. Sounds awesome. Break out the champagne. Ready the confetti. Or maybe do all that you can to eliminate meaningful commercial coverage so there will be nothing to compare to and the peasants will accept whatever you give them all for “free”?

  

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. LaMar Taylor of Bowie MD was charged this week for scamming Medicaid out of $600k using his day-treatment services company to submit bogus claims. Bertha Blanco, an employee of the FL HHS agency was popped this week for her role in a $1B Medicaid fraud scheme. Her crime? In exchange for bribes, she helped a shady nursing home operator keep their license, which was easy since she was a state inspector. It was a slow week this week – only a few cases. But we did rack up $1.06B in tax payer loss. Quality, not quantity dear readers. Mrs. Blanco – you win this week’s award!

I WILL BE AT MESC IN 1 WEEK, 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 (tomatoes are finally red) 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: Sang Rama ngutus Sang Putra nylametaké jagat

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Medicaid Acronym of the Day – SLMB

Specified Low-income Medicare Beneficiary – A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources.

Further reading 

https://q1medicare.com/q1group/MedicareAdvantagePartDQA/FAQ.php?faq=What-is-a-Specified-Low—Income-Medicare-Beneficiary-(or-SLMB)%3f&faq_id=199&category_id=1&parent_id=1

 

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Medicaid Acronym of the Day – QIO

Quality Improvement Organization – The QIO Program, one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries, is an integral part of the U.S. Department of Health and Human (HHS) Services’ National Quality Strategy for providing better care and better health at lower cost. By law, the mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. Based on this statutory charge, and CMS’s program experience, CMS identifies the core functions of the QIO Program as:

Improving quality of care for beneficiaries;
Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting; and
Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law.

Further reading 

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs/

 

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Medicaid Acronym of the Day – EMTALA

The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay, but since its enactment in 1986 has remained an unfunded mandate.

Further reading 

https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/

 

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Medicaid Acronym of the Day – CAHPS

Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys ask consumers and patients to report on and evaluate their experiences with health care. These surveys cover topics that are important to consumers and focus on aspects of quality that consumers are best qualified to assess, such as the communication skills of providers and ease of access to health care services. The acronym “CAHPS” is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Further reading 

https://www.ahrq.gov/cahps/about-cahps/index.html

 

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Medicaid Industry Who’s Who Series: Tom Meyer

Tom Meyer is the featured panelist for the upcoming Special Topic Webinar: 21st Century Cures Act on September 21st. RESERVE your seat today!

 

Medicaid Who’s Who: Tom Meyer – Chief Program Integrity Officer, HHAeXchange

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

A: Software and services for the home care industry

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

A: 11 ½ years

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

A: Creating efficient processes

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

A: Touring the USA

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

A: Cycling (think Tour de France, only slower)

6. Who is your favorite historical figure and why? 

A: George Washington.  Though he had many accomplishments, I most admire him for having voluntarily surrendered power (twice!)

7.  What is your favorite junk food?

A:  Chocolate

 8.  Of what accomplishment are you most proud?

A: My three daughters.

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

A: My lame marriage proposal.

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

A:  1. The replacement or adjustments to ACA (Obamacare)

2.  Value Based Payment Methodologies (and the data to support them)

3.  Funding Levels

Tom Meyer is the featured panelist for the upcoming Special Topic Webinar: 21st Century Cures Act on September 21st. RESERVE your seat today!

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Monday Morning Medicaid Must Reads: July 31st, 2017

Helping you consider differing viewpoints. Before it’s illegal. 

 

Article 1:  Ron Johnson: Medicaid expansion may be fueling opioid crisis. Todd Shepherd, July 27, 2017. Washington Examiner

Clay’s summary: That pesky Republican Senator from Wisconsin makes some good points.

Key Passage from the Article

 Johnson’s letter did not draw a perfect causal link between the two by suggesting Medicaid is the prime driver of the opioid crisis. But it offered up enough case studies to suggest that the expansion since 2014 has contributed.

Johnson told the HHS inspector general that internal data from the agency showed that overdose deaths, “largely from opioids, are surging much faster in Medicaid expansion states than in non-expansion states.”

“The number of convictions for improperly using Medicaid to obtain opioids, identified through such a cursory search, suggests a larger systemic problem,” Johnson concluded. “Because opioids are so available and inexpensive through Medicaid, it appears that the program has created a perverse incentive for people to use opioids, sell them for large profits, and stay hooked.”

Read it here 

Article 2:  Medicaid Reform. Heritage Foundation, July 27, 2017

Clay’s summary: Lots of pesky facts in this one. My favorite – when asked how the feds should focus Medicaid spending, 56% of poll respondents say the focus should be on the elderly and disabled. 46% say it should be for income-based groups instead.

Key Passage from the Article

By changing the formula reimbursement, Obamacare incentivized the addition of able bodied adults to the Medicare rolls. Eighty-three percent of the increase in Medicaid enrollment during 2014–2016 occurred in states that adopted the Obamacare expansion of able-bodied adults. Over the 3-year period (2014, 2015, and 2016), Medicaid grew 14 million; of that, 11.7 million (83 percent of total growth) occurred in states who expanded Medicaid to able-bodied adults. The increased funding to this group means there is less money available for the original beneficiaries of Medicaid—elderly disabled, pregnant women, and children in poverty.

Read it here

 

Article 3:  His Wife Runs Medicaid, but This Doctor’s Practice Won’t Accept It. Phil Galewitz, The Daily Beast, July 27, 2017

Clay’s summary: The headline is clickbait, but the rest of it is a good look at how Medicaid can not draw critical provider types like child psychiatrists into the network.

Key Passage from the Article

 Members of the Trump administration and Republicans on Capitol Hill repeatedly say the country’s Medicaid system is “broken” and enrollees struggle to get care because many doctors refuse that coverage.


The top U.S. official overseeing Medicaid—Seema Verma—doesn’t have to look far to find an example. Her husband, Dr. Sanjay Mishra, is one of them.
Mishra is a child psychiatrist in Carmel, Ind., and a partner and medical director of Indiana Health Group, a large medical practice specializing in mental health. That group doesn’t accept Medicaid.


“It’s sadly ironic, but given what I know… I am not one bit surprised,” said Dr. J. Wesley Boyd, associate professor of psychiatry at Harvard Medical School, who co-authored a study this year on the struggles children enrolled in Medicaid face looking for care.


Verma is administrator of the Centers for Medicare & Medicaid Services and a former consultant who helped design Indiana’s Medicaid program.


Jane Norris, a CMS spokesman, said Verma’s husband does not accept Medicaid because that “helps avoid any further conflict of interest or complication of her recusal obligations.”

Read it here

 

 

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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)