Category: Clay’s Weekly Medicaid Roundup

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2aeAX7r OR http://bit.ly/2aeAGBD

Or you can click the one for optimist readers – http://bit.ly/2aeB57a  OR http://bit.ly/2aBPHRo

 

SUCH A HISTORIC WEEK – Unless you have been under a rock (or perhaps engrossed in your Pokemon Go! adventure), you know this week saw a very historic milestone for our nation. Yes, dear readers, I am of course referencing the fact that a single healthcare fraud topped $1B for the first time ever.

 

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. Philip Esformes of Miami has set the world record with his $1B fraud robbing taxpayers who fund Medicaid. Esformes used his 30 nursing homes to bill for unnecessary procedures for Medicaid bennies. $1B people- $1B!! That’s 15,384 teachers (at an average annual salary of $65k). Heck, that might even cover 1 month of ACA premium increases. Staying in Miami for a moment, Fernando Mendez-Villamil was sentenced for 12 years for defrauding Medicare and Medicaid out of $50M. How did he get caught? At some point, he got on Chuck Grassley’s radar who noticed Mendez-Villamil wrote 96,685 scripts over 2 years for Medicaid bennies alone. Let’s head northeast to Chicago, where Gregory Toran was convicted of stealing $4.7M from Illinois Medicaid using his transportation company to bill for rides for dead people and for live people who never actually took rides. Now lets’ go way northeast on up to Anchorage, AK, where Mee Chong Collins stole $320,336 from Medicaid using false personal care services claims filed under her “Sunshine Care Services” company. Let’s move back towards the heartland, where Wendi Baker of Tiffin, OH was indicted for stealing up to $300k from Medicaid while working as a nurse at Blanchard Valley Health System. Hop on over to Oregon with me, as we watch Anthony Neal plead guilty to stealing $1.7M from Medicaid by using his clinic to order unnecessary tests. Total RoundUp reported fraud tab this week (not including the historic $1B from Mr. Esformes): $57M. Of course, Mr. Esformes, you win this week’s award!

 

WOW, JUST WOW- So much happened in the fraud space last week (much of it likely tied to another one of those coordinated drag nets we’ve seen the past few years), its almost difficult to think of much else. In the spirit of innovation, I will leave you with the rest of this week’s Medicaid news, in traditional haiku form (5-7-5):

 

News Item 1

Supplemental rule

Leaves OMB, goes to Prez

Cash this way rising

 

News Item 2

Bad times for Alere

Investigation slows buy

Kickbacks, fraud – oh my!

 

News Item 3

BlueGrass state looks back

Before leap, before Beshear

Plays chicken with feds

 

News Item 3

Public option lives!

Policy wonks remember

Prez gave C-P-R

 

News Item 4

Wolverine State plans

In the money, man oh man!

ACA cap rates high?

 

News Item 5

Brandstad marches on

Tells Dems and press to stuff it

Growing pains, he says

 

News Item 6

Anthem beats forecast

CIGNA deal still taking time

But rolls grew half-mill

 

News Item 7

UHC, Aetna

New Cal-forn-ya MCOs

Congrats on the win!

 

News Item 8

Caid’ Rx report

Abilify, Sovaldi

And Vynase top list

 

 

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 (its time to start planting a second crop!) and keep running the race (you know who you are).

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

News that didn’t make it and sources for those that did: twitter @mostlymedicaid
lu Patri mannau u Figliolu di salvà u mondu

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

Or you can click the one for optimist readers – http://bit.ly/2ahXf8T

 

ACA COSTS WAY MORE THAN EXPECTED/ADVERTISED? YOU DON’T SAY? Those meanie right-wingers over at Forbes just keep insisting on holding federal officials accountable to their cost projections for ACA. Per Forbes analysis this week, HHS 2015 ACA per-enrollee projected costs were off by 50%. While HHS said new ACA bennies would cost $4,281 per year, they actually cost $6,366 per year. Cue leftist explanatory gymnastics (but whatever you do, don’t suggest that government officials are either unable or unwilling to estimate the true costs of what they are proposing even as little as 1 year out).

 

BUT WE WANTED IT TO BE OUR IDEA! In NC, a huge push for Medicaid overhaul has been going on for a few years, and the state recently submitted an 1115 to CMS to bring managed care to the state. Now left wingers are directly pleading with CMS to reject it, arguing that the current Medicaid system in NC is just fine. Read between the lines and you will see that managed care is expected to reduce costs (payments) in NC Medicaid (which have been wildly unpredictable the past several years) and threatens the future of CCNC (a valuable – but also politically powerful – vendor of provider EHR and care coordination services).

 

ANOTHER EXPANSION TRIAL BALLOON IN TN LEGISLATURE- Volunteer State House Speaker Beth Harwell is getting back on the bicycle to try yet another flavor of expansion. This time she is hoping a focus on vets and mental health will be the push that expansioners need to get a plan passed.

 

CMS TO UTAH: “TALK AMONGST YOURSELVES” If you’ve been following the planned UT expansion here in the RoundUp, you know it’s a pretty focused approach – chronically homeless, in the justice system or needs MH/SA help. So CMS will be very careful with this one, and this week they asked UT to get some more public comment in their state before CMS reviews (and opens their own public comment period). CMS has specifically noted that the budgetary portion of the proposal was not finished when the UT public comment period ended. My guess is they won’t get any “aha moments” from extended comment, but it will be interesting to see what the “input” from the public is on the costs. “You’re spending too much on this” – said no Medicaid bennie or advocate ever.

 

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. Ted Suhl of Little Rock, AR got convicted of bribing a Medicaid official this week. Seems Mr. Suhl paid off AR DHS Deputy Director Steven Jones (who plead guilty last year) to make sure Suhl’s mental health companies got $90M in Medicaid moo-lah. Cynthia Harlan of Charlotte, NC was convicted this week for her role in a $10M services-not-provided scheme. Paul Mil of Springfield, NJ is headed to the big house as of Thursday. Mr. Mil nabbed $7M of your tax dollars using a bogus home health Medicaid scheme (unqualified providers, fake claims – surely, and sadly, you can fill in the rest of the sentence by now dear RoundUp reader). Patricia Torrington of Bridgeport, CT was sentenced for $1.6M in bogus Medicaid psychotherapy services.  Mr. Suhl – you win this week’s award by a landslide! Maybe you and Mr. Jones can be cell mates? I’m sure he will remember you as a friend for all those bribes you paid him when he was a state government employee. (Lots of honorable mentions for the follies in the twitter feed this week, folks).

 

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 (or maybe stay in- its HOT!) and keep running the race (you know who you are).

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

News that didn’t make it and sources for those that did: twitter @mostlymedicaid

Fùqīn sòng érzi lái zhěngjiù shìjiè

Clay’s Weekly Medicaid RoundUp: Week of July 4^th, 2016

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/29zczxr

Or you can click the one for optimist readers – http://bit.ly/29FFLFP

Hope everyone had a great 4^th of July. For all you folks educated in the public school system in the last 20 years, let me help you out with a clear telling of what happened 240 years ago. The 4^th of July is when we celebrate some of the best men ever to have lived declaring that we would be ruled by laws, not corrupt tyrants. It is not about hot dogs or fireworks – but you do get to enjoy those things because awesome men called “the Founders” started something called “America.”

VOLUNTEER STATE ROLLING OUT HEALTH HOMES IN 4 MONTHS- TN’s Health Link program will serve behavioral health members by coordinating their primary care and behavioral health care (that whole integrated care thing). Providers will get a monthly cap for the coordination service between $70 and $140.

NO DICE FOR NO-SHOW FEE IN SHOW ME STATE- Doctors in MO are taking a hit with a high missed appointment rate for Medicaid bennies. So they wanted to have a fee imposed to members- $5 for the second missed visit, $10 for the third, and $20 for every visit missed after that. The Good Guvn’r Nixon vetoed the bill, saying it would be “gouging the poor.”

BUDGET WATCH- KS hospitals are phoning-a-friend (the federalis) to try and stop cuts enacted to deal with the budget deficit. In an open letter to CMS, the KS Hospital Association pleads with the feds to stop the $54M in cuts that would hit hospital pockets. AL docs will see the primary care payments boost come to an end starting this month. As part of AL’s $85M budget shortfall, the Medicaid agency decided to stop enhanced payments enacted originally using ACA one-time monies.

EXPANSION WATCH- AR shot its revised expansion plan over the bow this week, complete with a list of evil, access-killing requirements. If approved, the new gig will send unemployed bennies to work training programs, end 90 day retro eligibility, provide dental for bennies who pay their premiums and require bennies between 100 and 130% FPL to pay a premium that’s no more than 2% of their income (what % of your income is your premium, dear reader?). Move over west just a little, and the Good Guvn’r Bevin (KY) and CMS are now in talks over his plan to change expansion in the state. Bevin has rolled out new rules related to work requirements (including an allowance for community service) and encouraging transitioning from Medicaid to commercial insurance. According to Bevin’s team, the changes will save the state about $331M over five years. Bevin wants approval by September; CMS is saying there’s no rush in reviewing the request. If you read between the lines, Bevin is sort of saying to CMS – accept these changes or we un-expand. I like it.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Seven DE DHHS case workers were indicted for stealing $959k in food stamp benefits. “Drs” Chethan V. Byadgi and Rajaa Nebbari of Scranton, PA got their plea deals rejected last week- their crime? Allowing non-licensed staff to write scripts for narcotics and filing $159k in false claims to Care’ and Caid’. “Dr” Monaco of Haverford, PA operated A Foot Above Podiatry and stole $5M via false claims (services not provided). Misty Baker of Brandon, VT stole $77k using faked time sheets for the VT Children’s Personal Care Services program. Wow, what a diverse week we had for fraud! We even had a nearly $9M foodstamp fraud in our lil’ ole Medicaid column. That being said, you can only win if your fraud is for Medicaid (and at least $50,000 – to weed out the amateurs). “Dr” Monaco – you win this week’s award!

A WORD ON OUR WEBSITE- To all those who visited our site the last few weeks, you may have experienced downtimes and malware warnings. We have just completed a relaunch with a new hosting provider, and should be good to go. I apologize for the inconvenience. I promise we are not Estonian hackers trying to get your SSNs. Although there probably are some of those doing just that right this moment- in order to file false Medicaid claims, of 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 (the tomatoes are coming in!) and keep running the race (you know who you are).

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

News that didn’t make it and sources for those that did: twitter @mostlymedicaid

hkamaeetawsai kambhar  kaalhphoet  sarrtawko hcay lwhaattaw muu

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/1UGzggU

Or you can click the one for optimist readers – http://bit.ly/1UGznci

BEAVER STATE 1115 ON SCHEDULE- Oregon will be submitting more of a continuation waiver than major changes for its Care Coordination Organization (CCO) model. The first major report on the CCOs for the state will be July 1 this year, with the waiver renewal application timed for late summer. According to the Good Guvn’r Brown, she wants to get it approved before the White House changes hands. Maybe she knows something we don’t?

BUCKEYE STATE GETS NOD FROM THE BIG HOUSE- Ohio just got CMS approval for their plan to move nursing home residents back into the community. OH has been doing this already, with 8,000 residents driving away in a U-Haul with crying nursing administrators staring at tail lights.

NATURAL STATE ADDS 25,000 TO THE ROLLS SINCE FEB- Despite all the legislative brinksmanship this spring, AR still found a way to grow the expansion rolls to 290,000.

SOONER STATE DOCS DODGE A BULLET- It was dire and desperate in OK up until last week. Medicaid providers faced a 25% rate cut. But somehow, magically – no miraculously – state legislators were able to give Medicaid $99M more this year compared to last. Amidst a $1.3B state budget shortfall. I truly am in the right line of business. Medicaid, you need way more money every year? Sure thing! Education, roads, everybody else – sorry!

PEACH STATE WARMS UP TO THE SUGAR MONEY- State Senator Renee Unterman shot down ACA expansion cash, but is now suggesting (on the state senate floor) that GA should consider doing an 1115-style expansion instead.

HOOSIER STATE CLAIMS “THE TEACHER DOESN’T LIKE ME”- IN got an emergency approval of its “conservative” (reads – not nearly as far left as the administration likes) Medicaid expansion plan this April. Now CMS is surveying members to see how they like the “conservative” approach, and IN says the surveys are biased against their model. And it sort of matters beyond IN – states like AZ, KY and OH would like to get them one of those new-fangled “conservative” Medicaid expansions, too. Who knew Medicaid could be so political? I thought it was just healthcare, right? The main Hoosier complaint is that there are plenty of questions about why you might be dissatisfied with the plan, but none asking why you are satisfied with it. Apparently question #17 had some rattled. The survey question reads: “Are you now, or have you ever been, a member of the Republican party?”

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. Barbara Sadler and Sedric Blakes of “Extraordinary Care Network” were convicted on a $1.2M Medicaid fraud charge this week in Baton Rouge, LA. Their crimes? Billing for one on one therapy that didn’t happen, forging signatures and fabricating client progress notes. Jennifer Green and Andria Jones of Jackson, MS got popped this week for a $1M fraud in which they got paid for bogus counseling claims. Candia Tolbert, who operated “No Child Left Behind Behavioral Health Services,” was convicted this week on $100k for false claims. Congratulations Barb and Sedric – you win by a hair, just barely beating out Jennifer and Andria.

REMINDER – NO STATE SPOTLIGHT SHOW THIS MONTH, BUT STILL DOING THE NEWS ROUNDTABLE SHOW– I know people plan their weddings and other things around those, so just trying to get the word out.

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 (the sun is up earlier now!) and keep running the race (you know who you are).

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

News that didn’t make it and sources for those that did: twitter @mostlymedicaid

Otets prati Sina , za da spasi sveta

Back from one of my infamous breaks. One of the interns told me that CMS passed some sort of “Mega Rule” while I was out. That doesn’t sound too terribly important, so we’ll skip it for today.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/1ZiOmgC . Trust me, its cool. Click it. You know you want to. Or you can click the one for optimist readers – http://bit.ly/1ZiOwEI

As is our custom here in RoundUp Land, when returning back from a break, let’s start with the red meat.

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. Florence and Michael Bikundi of D.C. just got sentenced for the largest ever Medicaid fraud against the District – a whopping $80M over 5 years. They used their home health company – Global Health Care Services – to enrich themselves and relatives by paying Medicaid bennies kickbacks for lying about claims for services not provided. Edward and Contina Foxx of Bedford, VA got sentenced this week for bennie fraud. They received $80k of Medicaid benefits but failed to report $500k in income they got from their scrap metal business. Mary Ann Stewart (such a wholesome sounding name, amiright?) of Pittsburgh is going to the Big House (not CMS, the other one) for operating a bogus hospice. She nabbed $500k from Medicare and Medicaid by admitting members who weren’t actually terminally ill. But doesn’t hospice require a doctor saying you need it? Yep – “Dr” Oliver Herndon helped Mary Ann out there with bogus claims. He got 3 years for his part of the fraud. “Dr” Naimetulla Syed of Newtown, CT got popped for $400k in upcoding Medicaid psychiatric claims. Seems he liked to bill for 45 minutes of therapy but only deliver 30 minutes. A housing and assistance company that serves DD members in Middletown, CT has to fork over $1.5M for falsified cost reports. Mobile Pharmacy Solutions of Buffalo, NY has to pay Medicaid $442k for filling scripts for a barred doc (“Dr” Mikhail Strutsovskiy). Still in the Empire State – Andrew Barrett, a pharmacist from Queens, pled guilty this week for $2.7M in bogus HIV meds scripts. And finally, “Dr” John P. Moore the 3^rd (I imagine him with a monocle and cigar, much like Thurston Howell the 3^rd on Gilligan’s Island) was sentenced to 20 months in the slammer for $80k worth of Medicaid fraud. His rap sheet now also includes drug trafficking, theft and permitting drug abuse. Phew! A lot happens in a few weeks’ time. So many to choose from… This week’s award goes to the 2 lovebirds in D.C.-  Mr and Mrs Bikundi – enjoy your stay in the jailhouse. Maybe you can get the Honeymoon Suite?

OFF ™ SALES TO SKYROCKET AFTER MEDICAID COVERAGE- Zika is our latest microscopic enemy, and the federalis just approved Medicaid cash for Mosquito repellant.

THE LEVEE BREAKS- The Hep C rx spending tsunami is set to obliterate already anemic state budgets after a string of lawsuits (and threatened lawsuits) felled any remaining speed bumps in several states last week. FL and WA both announced less restrictive coverage policies, and PA is on the brink of falling in line.

IF ONLY I KNEW A WELL-CONNECTED MEDICAID ENTREPRENEUR- The Big House (CMS, not the other one) knows it needs some innovation from the private sector and is reaching out. Its doing a road-show with tech firms (Slavitt went to Silicon Valley this week) trying to gin up some techie brain power. They also have a sort-of job posting for a “well-connected entrepreneur” to serve as a “Sherpa” to help tech companies get to know Medicaid. Anyone ever met one of those?

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 (the sun is up earlier now!) and keep running the race (you know who you are).

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

News that didn’t make it and sources for those that did: twitter @mostlymedicaid

Otac je poslao Sina da spasi svijet

BUCKEYE STATE ON FOOLS ERRAND- Ohio has the laudable, but laughable, goal of implementing a requirement that Mcd bennies chip in $99 bucks (or about 1.5 cartons of Marlboro Reds in Ohio) a year. The member contribution would go to a health savings account. There would also be new copay requirements (the state would dump a grand into the HSA to help with those). I give this less than a 5% chance of passing given the “your-evil-for-even-suggesting-there-be-the-slightest-cost-to-the-member” mentality of most of those in our Mcd world.

EMPIRE STATE CONSIDERING MCD COVERAGE FOR EX-CONS- The Good Guvn’r Cuomo is horse-trading with CMS as we speak to get Mcd funding for the plan. His plan appears to be a limited scope benefit, designed to help with substance abuse and a defined set of medical conditions.

UPDATE ON AL MCD USING BP OIL MONEY FOR FIX- It didn’t happen. Seems that some state senators wanted to use the money AL got to deal with the coastal disaster on roads instead of Medicaid. Officials are now foreshadowing the areas to be cut the most. It’s getting hot down here, and its not even June.

SUNFLOWER STATE SLOWS DOWN ON WAIVER INTEGRATION PLAN- The Good Guvn’r Brownback of KS will not veto a legislative directive to stop efforts on the integrated waiver services for Kansans with disabilities. The planned waiver was aimed at increasing HCBS services for members, but advocates were concerned of the speed and ambiguity of the plan.

WE DID NOT THINK OF THE IMPACT OF THE MINIMUM WAGE HIKE ON MEDICAID COSTS, COMRADE- When NY decided to raise its minimum wage from $9 to $15 by 2018, seems no one did the fiscal impact analysis on Mcd costs. As we in our insulated, behind-a-computer-or-on-a-plane-each-week jobs often forget, the healthcare industry employs many minimum wage workers. This provider increase (the wage hike) will add $13M to this year’s NY Mcd costs and $88M to next year’s. And the year after that, and the year after that . . . No worries. Close your eyes and remember the money trees in Washington, D.C. They’re so pretty this time of year.

LOTS OF LITIGIOUS PAYDAYS FOR STATES- Lots of cash flying around this week, mostly from big pharma to states. KY got $5M from Pfizer related to drug rebates not paid on Protonix (an antacid drug – [INSERT HEARTBURN JOKE HERE]). IN got $9M from the same lawsuit. WA got $23M. Total payout to all states and federalis was $784M (ouch, Wyeth. But at least you can move on and watch the stock price rise now that the settlement is done, right?).

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph.   Wayne Wilson of Statesville, NC is headed to the big house for 18 months for stealing $210k for services he did not perform. Wayne is a doc who thinks Mcd didn’t pay him enough, so he “padded” his claims. Dwight and Charmetra Reece (man, there is a lot of husband and wife Mcd fraud) of Oklahoma City were charged this week with stealing $99k from Mcd. The couple operated a counseling agency and billed for services not delivered. Including payments for Charmetra’s mother (who is not a licensed counselor). Agape Health of Alexandria, VA has settled with Mcd this week over allegations it billed for transportation services not provided. Total bogus cab fare – $386k. Agape – you win! Follow that cab! (to jail. Do not past Go.)

I CAN’T NOT WRITE ABOUT THIS- George Clinton will release a new album this year entitled “Medicaid Fraud Dawgs.” I am not making this up.

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 (the sun is up earlier now!) and keep running the race (you know who you are).

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

News that didn’t make it and sources for those that did: twitter @mostlymedicaid

Pitāra biśba sanrakṣaṇa putrakē pāṭhiẏēchilēna

BRITISH PETROLEUM TO FUND AL MEDICAID- Lawmakers struggling to scrounge up funds to fill the Mcd budget gap have come up with a way to leverage money the state is owed from the BP oil spill. It’s a little tricky for me to understand but it involves a bond issue that then gets paid off with BP money and I think somehow a new (or quicker) $85M pops out to plug Mcd. Not sure yet on the reaction from coastal residents who may see the move as snatching the funding tied to the devastation of their environment six years ago.

EMPIRE STATE TO COVER HEP C DRUGS- This follows a recent lawsuit requiring commercial plans in NY to cover drugs like Sovaldi and Harvoni. There are 25,000 new Hep-C cases in NY each year. At some point, each of those could become eligible for the drug, creating a new $2B annual spending item for Hep-C rx alone.

LA MEDICAID EXPANSION IS ROLLING OUT NOW- The state is beginning to migrate members from existing programs that already meet the Mcd expansion population requirements. Members of Take Charge Plus and New Orleans Community Health Connection were asked to update addresses this week so that they can receive their brand new Mcd cards.

AZ HOSPITALS RECEIVED MORE THAN $1/2B RETURN ON THEIR MCD “TAX”- The Medicaid Magic Money machine strikes again. St Joe’s had the biggest ROI on the “tax”, receiving more than $24M than it put in. The money trees in D.C. did look a little sickly last week, but they were watered and rebounded quickly.

MOUNTAIN STATE WILL GLADLY PAY YOU ON FRIDAY FOR A HAMBURGER TODAY- It’s never a good sign when the Mcd agency sends you a letter saying it may be a while before you get paid because state revenues are down. Yet that’s what WV did to 24,000 Mcd providers this week. At least they gave you a heads up, I guess?

MCO WINS IN THE KEYSTONE STATE- Centene and UPMC won bids in SE PA this week under a new effort to negotiate pay for outcomes MCO contracts (up to 30% of payments tied to outcomes). Congrats to our friends and colleagues in Centene and UPMC!

AH, THE MEGA RULE- As most of you by now know, the final Medicaid Managed Care Rule was released Monday. There’s simply too much to cover but 2 quick things- the already voluminous 653-page rule more than doubled itself to 1,425 pages (maybe they fed it after midnight, or got it wet?). And #2- everyone I know says it seems like CMS just ignored most of the comments. Not sure on that last one, but hope to do a show on it soon and have some good discussion on it.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Darin Cox of NY got $80k in Mcd payments for his taxi service carting bennies to appointments. Thing is, he didn’t have a taxi license. Robert Rouzaud of Cleveland, OH got charged this week for false Mcd claims for tooth fillings. Mr. Rouzad got paid $343k for fillings for teeth that had previously been pulled, or for patients with dentures. And in one of our rare (rarely detected, anyway) cases of member fraud – Jennifer Garret of Chandler, AZ got indicted this week. Mrs. Garret received more than $70k in Mcd (and other) state benefits, all while her and her husband made loads of cash on their car restoration business. Enough to buy a Nissan 350-Z and Mercedes SUV while toting a Medicaid card in her pocket. Mr. Rouzad, you win! Mr. Cox – perhaps you should consider an Uber career? Mrs. Garret – perhaps Mr. Cox could borrow your Mercedes if he gets out before you do?

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 (remember to water those seedlings!) and keep running the race (you know who you are).

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

News that didn’t make it and sources for those that did: twitter @mostlymedicaid

Ata dünya saxlamaq üçün Oğlunu göndərdi

Join me on a magical Medicaid movers and shakers tour, this week organized mostly by state and those organized by year they entered the Union (because its interesting) …

THE OLD COLONY STATE (1788) CAN’T TELL THE GOOD GUYS FROM THE BAD GUYS – WHY CAN’T THE BAD GUYS JUST WEAR BLACK HATS LIKE THEY DID IN THE OLD WESTERNS? MA State Auditor Suzanne Bump released a report this week showing about $427k in claims to providers who were supposed to be barred from the Mcd program. Just like the punchline of every research study is “needs further research,” this audit followed the audits script and ended with “insufficient internal controls.” Most of the no-no payments went through MCOs – similar to a report last year showing MCOs paying out $500M in improper payments (not all to barred bad guys, though).

THE HEART OF IT ALL STATE (1803) GETS THE TAB ON LONG NIGHT OUT AT BAR- One of those evil, mean, terrible – dare I say – conservative!?- watchdog sites has started reporting on the costs of Mcd expansion in OH. The Good Guvn’r has swelled spending by $7.9B so far for his expansion efforts. That’s worked out to be about $394M of additional Mcd spending each month since expanding. But don’t worry – everyone knows most of that is not state money, it’s federal money. And we all know federal money grows on the money trees in D.C. Haven’t you seen them lining the streets when you visit the nation’s capital? They bloom each spring, and millions flock to see them. They’re right next to the giant beanstalk that sprung up from one of Jack’s beans. And that, children, is how Medicaid financing works.

THE NATURAL STATE (1836) PLAYS OPPOSITE DAY- AR policitians used a poison-pill maneuver to save the hybrid / private option expansion plan that’s been the darling of dems and the thorn in conservatives’ sides for a few years now. Legislatures shrewdly put in a provision to end the expansion, which the Good Guvn’r Hutchinson vetoed – so by saying no, he said yes to what he and his allies wanted. And the program is thus extended. You have to admire such brilliant tactics.

THE WOLVERINE STATE (1837) IS IN THE MONEY (WELL, THE MCOS ARE ANYWAY)- Reports of skyrocketing MCO profits came out this week, all tied to the new Michigan contracts and expansion. According to one source, MCO profit grew 627% when the state took the ObamaCare deal. The state health plan association targets a 2% annual profit margin; the surge in underwriting income now has it at 3.9%. Not to worry – association execs assure us that this “double the target” profit margin is helping to make up for lean years past.

THE LONE STAR STATE (1845) GETS A CIVICS LESSON- If you’re following the TX Medicaid cuts ordered by the legislature (apparently that’s some sort of branch of government elected by “popular vote” that still has some amount of power, but truthfully I was always taught in government school that Judges rightfully run this country), you know that there have been a few stands in the courthouse door to stop the agency from following the law. Thursday saw an appeals court uphold the cuts, frustrating activist hero Judge Sulak, who remains convinced he gets to decide what TX does with all that Medicaid money, not those pesky “elected representatives.”

FARRIS’S FANTASTIC FRAUD FOLLIES– Just not enough space this week my fraudster friends. Lots of good stories in the twitter feed for those who need their fix.

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 (spring planting is done!) and keep running the race (you know who you are).

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FULL, FREE newsletter: http://eepurl.com/ep81Y

News that didn’t make it and sources for those that did: twitter @mostlymedicaid

Hayrn ugharkets’ ir Vordun p’rkelu ashkharhy

GOLDEN STATE WANTS ITS MONEY BACK- By now I don’t even have to tell you the details. If “MMIS” is in the sentence, you can tell me the rest: overbudget, late and ugly. CA just signed the divorce papers with Xerox (old ACS for anyone returning to the space, or those – who like me- never could make the mental switch from ACS to that company that makes copiers). The implementation is far from finished, but the state has decided its better to just start over. I’m sure CMS is happy, since they paid 90% of whatever has been paid so far. Xerox has agreed to pay the state $120M, and continue operations until 2019. Ouch.

BEEHIVE STATE EXPANSION COULD BEGIN NEXT YEAR- If CMS approves it. The main hitch is that the UT plan will cover about 16,000 new members. If UT has just been a good little soldier and taken the expansion exactly as offered, about 100,000 would have been covered. The expansion will cost UT $30M each year, and hospitals have volunteered to be “taxed” to cover about half of that.

PINE TREE STATE POLITICIANS PASS SYMBOLIC EXPANSION VOTE- Dems in the Maine Senate and house passed a largely meaningless bill this week- but everyone still expects the big bad wolf, er, I mean the Good Guvn’r LePage to veto it. Don’t count it out just yet – the GOP governors have fallen one by one on expansion the last few years. LePage just needs to figure out how to make it not look like “ObamaCare” in the press release.

LONE STAR STATE CUTS GO THROUGH – TX Medicaid agency have to follow the budget as passed by the legislature (egads!), which includes $350M in cuts. Although our hero, District Judge Tim-Screw-Checks-and-Balances Sulak blocked the cuts made in accordance with the law of the land last September, the TX Health and Human Services Commission testified this week that it has to follow the legislature’s instructions and make the cuts.

UPDATE ON OUR SUPPORT VETS FUNDRAISER- Last week I asked for suggestions on a charity we (the Mostly Medicaid Motley Crew) could all donate to between now and 4^th of July. All you Readers who wrote in – thank you! I got several great suggestions, and will start running links to them in the newsletter each week until 4^th of July. I don’t know a really good way to calculate how much we all give combined (and that’s not the point anyway). If you do give to one of those listed, please post a note in the Mostly Medicaid LinkedIn group, or comment on one of my posts related to this. $ amount doesn’t matter – let’s just encourage and challenge our healthcare industry colleagues to show support with a focused effort the next few months.

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Shifo Healthcare Services (a home health company) of Ohio is under investigation for $2M in overpayments as of this week. OH Auditor Dave Yoast is digging but not finding documentation supporting the claims. Yury Baumblit of NY runs a flophouse (had to look that up), and got charged this week with $2M in Medicaid kickbacks related to addicts living in the flophouse. Seems Yury forced tenants to attend Medicaid group therapy sessions for substance abuse, and providers paid Yury and his wife (Rimma) kickback fees. Step by Step Senior Care (another home health company) of Little Rock, AR agreed to pay back $472k this week for charges related to billing for imaginary patients. Miami fraudsters David and Cecilia Krochmal were arrested this week for $100k in Mcd payments related to services not delivered for I/DD members. Mr and Mrs Baumblit – you win! And wow. That’s some really terrible stuff.

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 (spring planting almost done!) and keep running the race (you know who you are).

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

News that didn’t make it and sources for those that did: twitter @mostlymedicaid

‘arsal al’ab w alaibn li’iinqadh alealam

 

OH MY DEAR TARHEEL STATE, WHY CAN’T YOU GET IT TOGETHER? I love NC. Heck I lived there for 2 years. But its time for an intervention. News of $835M in misspent 2015 Mcd funds came out this week. Agency officials acknowledge the problem of improper payments, but challenge the number (but don’t provide an alternative number). Beth Wood (the state auditor) is sticking by her $835M number, which is based on a sample of 396 claims. For those of you with an NC connection (which is a lot of us in the Mcd world), you know this is just the latest bump in the road.

MO PUTS FOOT DOWN ON MCD BUDGET; IN OTHER NEWS HELL HATH FROZEN OVER- The Mcd agency was asking for an increase that would have consumed all new state revenues for the fiscal year. Instead, the Senate came back with a $55M cut for Mcd in the Show Me State. News of this unprecedented event (an actual cut to a Mcd budget, not a “we would have spent even more, so give us 10% more than last year and call it a cut”, cut) was immediately followed by swarms of locusts, great cracks in the ground swallowing cars and the Mississippi River turning to blood.

TEMPEST IN A TEAPOT: IOWA MCO TRANSITION GOING JUST FINE- The move to managed care can be painful. You’re taking what has been run by the government for decades, spawning hundreds of mini, protected, subsidized fiefdoms – and converting it into something that has to be run efficiently enough to turn a profit. There’s some growing pains. Iowa became the 39^th state to make the switch to managed care this week, but only after months of “the sky is falling” and ripping of sackloth from the legacy stakeholders. As long as the Good Guvn’r Brandstad is right, there wasn’t much to fuss about. The transition is going smoothly. We can all hope for a 6-month honeymoon, at least until the MCOs begin the obligatory “our rates are too low, so this is why the sky is falling now” wailing. See- the sky is always falling in Medicaid. It’s only a question of who’s playing Chicken Little.

MCD EXPANSION = BOON TIMES FOR LOBBYISTS- If KY is any indication, anyway. Looks like health related lobbying has ramped up 30% this year compared with last. I think they measure that based on reported payments to lobbyists, but not exactly sure. Would love to hear what you are seeing in your statehouse if your state is one of the expansion holdouts.

ANYBODY KNOW A GOOD CHARITY FOR VETS? For the last several years I have wanted to do a fundraising campaign for vets to be timed with Memorial Day / 4th of July. Both always sneak up on me … If you have a good one you recommend, please email it in.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Start the ticker and let’s see who wins this week’s award. Elva Santos and Manuel Gomez of TX got pinched for two very similar (but not related) scams this week. Santos pilfered $581K of Mcd dollars with her DME company; Gomez did the same with his, but added a patient data buying scheme to the charges. Gomez’s tab rings up at around $2M.  Christina Benson of Tallahassee plead guilty Mcd fraud- she got $170k by paying homeless men and women to pretend to be Mcd patients and then bill for home care solutions they did not need. Mr. Gomez – you win!

 

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 (its almost time to plant!) and keep running the race (you know who you are).

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

News that didn’t make it and sources for those that did: twitter @mostlymedicaid

ābi le‘alemi hone kewelidi bek’eri welidimi