Category: Clay’s Weekly Medicaid Roundup

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.

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.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2zqq6nM

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

 WELCOME, MRS. MAYHEW- After bringing some predictability to the Maine Medicaid budget, Mary Mayhew was tapped to head Medicaid efforts at the federal level earlier this month. Her official title will be CMS Deputy Administrator. Congratulations, Mary!

BADGES? WE DON’T NEED NO STINKIN’ BADGES- If you thought CMS was holding the phone on work requirements while the KY lawsuit sorts out, you were wrong. CMS approved Wisconsin’s request to add a work requirement feature to its Medicaid benefits package. Also important- Wisconsin is a non-expansion state (many work requirements resisters have been holding out hope that CMS won’t approve work requirements in non-expansion states). CMS did not approve the state’s request to add drug testing requirements for members, but they did allow them to ask bennies about risky health behaviors as part of coverage determinations.

  

NEITHER DOES VIRGINIA- Sources say VA officials plan to submit a work requirements request to CMS by this Friday. Current proposal includes work/volunteer requirements (or job classes) and premiums up to $10/month. Many conservative lawmakers feel the new proposal is too watered down to matter, though.

 

 POSSIBLY ALSO NEITHER DOES MISSISSIPPI- MS Medicaid officials are chatting it up with CMS now that the public comment period on their work requirements request has ended.

  

NEBRASKA VOTERS TO DECIDE EXPANSION AS WELL AS WHICH MODIFIERS SHOULD PAY ON 99213 CODES IN THE NEXT VERSION OF THE POLICY MANUAL- Initiative 427 puts Medicaid expansion in the hands of Nebraskans next Tuesday. I’m not concerned they are low-informed voters on the details of Medicaid. Not at all. Nothing to see here. Move along.

 

 VERMA TROLLS MEDICARE-FOR-ALL MOB; THEY TAKE THE BAIT- Hey if Nebraskans who mostly probably don’t know the difference between Medicare and Medicaid can decide whether to double spending on it, why can’t the twitterverse tell CMS Administrator Verma (in the very polite ways we have come to expect from our leftist friends, of course) she was a terrible, doubleplus ungood person to tweet this in the spirit of Halloween. Remember, questions like “how would we pay for it?” and “does this even make basic logical sense?” don’t matter. All that matters is feelings and a deeply held conviction of a virtuous “resistance.”

 

OHIO MOVING UP HEP-C TREATMENT- Medicaid bennies in OH no longer have to wait until their Hep-C progresses to get specialty drugs. Starting Jan 1, OH will pay for treatment for any one diagnosed with Hep C. In tech speak, OH used to pay for patients with a Fibrosis Score (F score) of F2. Now the state will pay for all Fscores (starting at F0). Last year the state went from only paying for F4s to F2s.

  

CA PAID $4B OUT IN “QUESTIONABLE” PAYMENTS- Some pretty egregious examples in a recent state auditor’s report. Biggest findings – state kept paying MCOs and docs for services for 453,000 members who were ineligible for benefits. Worst example- an MCO got paid $383k for care for a member in LA County who had been dead for 4 years.

  

FINALLY, AFTER 300 YEARS, CMS APPROVES NC WAIVER- Congrats to the team that’s been working on bringing managed care to the state for the past few years!

 

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. Edwardo Yambo of Lake Grove, NY stole $939k for false lab claims. In addition to billing for claims his lab wasn’t even equipped to run, Mr. Yambo operated the lab without a director (a big no-no). Lanice Stamps and Tia Smiley of New Orleans were convicted this week for their $1.1M fraud in Louisiana using a bogus behavioral health company to steal from Medicaid. Bonus – both fraudsters were also Medicaid bennies. Not sure I have seen double-dipping on the provider and benny fraud side before. Nikkita Chesney of Bridgeport, CT plead guilty this week to using 150 stolen member IDs to file more than $1M in false claims. Celestine “Tony” Okwilagwe lead the way in convictions for a pretty large home health fraud in Dallas this week. Along with 3 of his buddies, Tony got popped for stealing $3.7M from Medicare and Medicaid. Special points on this one since 2 of these dudes had already been excluded from any federal health-care program for prior convictions. Matthew Neiswanger of Baltimore was in court last week and agreed to pay back $2.2M his nursing home stole from Medicaid. How did he do it? Evicting higher cost patients (sicker) and false claims. Joseph Dubin and David Dubin (father and son, a first for the follies) of Austin, TX were convicted of stealing $300k in a kickback scheme involving Medicaid psychology services. Fraudster and Sons paid another fraudster to refer Medicaid kids to their mental health services company. Lanice and Tia you win – I am just entranced by the double provider/member fraud angle! Plus, $1.1M is a pretty good take home. Taxpayers, you lose – about $8.2M in the stories covered in this paragraph. Work harder! Gotta pay for all that fraud somehow…

New content alert- The Medicaid Fraud, Waste and Abuse Curator Volume 1 is out. Includes links to the stories above and a lot more. Check it out here.

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 (clean your chimney, its that time already) and keep running the race (you know who you are).

 

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: piyāṇan vahansē lōkayaṭa gaḷavannaṭa putrayā evū sēka.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2RI7RCi

For optimist readers- http://bit.ly/2RKh1hW

 

BUCKEYES TO GET MORE OPTIONS ON OPIOID RECOVERY MEDS- Based on what I am hearing, looks like Ohio may be removing prior auth for more drugs besides just suboxone and generics for buprenorphine and naloxone. If you know more, please dial into the show on Monday and weigh in.

 

NEW PROJECT TO UP CAID IMMUN RATES- If you’ve been around this Medicaid world a while, chances are you have bumped into the immunization “registries” (glorified excel files in a Medicaid official’s computer, usually). The CDC is funding a new consulting project (Nat’l Academy for State Health Policy got $800k) to figure out how to better integrate this data, encourage providers to submit more of it and close gaps for certain vaccines (i.e. Medicaid rotavirus rates for kids are 12 points lower than commercial).

  

MORE RUH-ROHS IN THE OH PBM SCANDAL- We will cover this in Monday’s show, so tune in. The gist: turns out one of the reasons Centene’s rx costs were more than other MCOs (all of them got caught up in the spread pricing scandal), is because they used their subsidiary (Envolve) as a sort of middle-middle man to the PBMs.

  

HOW MANY YEARS IS IT OK TO NOT HAVE A MEDICAID INSPECTOR GENERAL IN A STATE? 4 years is the answer if you’re Kansas. After the top Medicaid oversight spot (over the $3B program- but hey that’s chump change when its those taxpayer chumps funding it, right?) sat empty since 2014, the seat is now being manned (wo-manned, actually) by Sarah Fertig. Congratulations, Sarah!

 

CONGRATS TO OUR FRIENDS AT WELLCARE- It’s the time of year where we see which MCOs are doing better per NCQA quality ratings, and Wellcare just got high marks in NJ and NY. Congrats!

  

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. Vicki Chisam of Batesville, AR was charged with her role in a $2M Medicaid fraud (part of the Preferred Family Healthcare mental health scheme we have covered). Chisam was apparently the EHR data manipulation specialist in the crimes. She herself is tied to $589k in pilfery. Lyubov Beylina of Brooklyn (along with 7 other upstanding citizens) was charged with stealing $600k for billing for therapy while on vacation in the Dominican Republic. She also forged signatures of parents of children she was therapy-ing. Joanna Michelle Phillips of Cheyenne, WY was sentenced to 18 months for stealing $58k via false claims. Mercy Ainabe of Houston, TX was sentenced this week for her role in a patient recruitment Medicaid fraud scheme. She and her fellow fraudsters used a home health care front to bill for medically un-necessary services, pay bennies to sign-up and send kickbacks to docs. Total tab – $3.6M (but to Medicare, so she can’t win this week). Epo Onega of Staten Island was popped for using her teaching job to steal $59k with bogus speech therapy claims. Vicki- you win! Hopefully you can re-connect with some of your old workmates once you all get sentenced. Taxpayers – you lost about $7M in this paragraph! Work hard! Somebodies gotta pay for all this fraud (hint- you do, chumps). Are you a Medicaid bennie on a waiting list for a waiver program? Keep waiting! Sorry, we have to make sure we keep paying fraudsters before we open up your slot.

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 mums – they can actually do really well in the ground) 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: Otac je poslao Sina da spasi svet. Also – chuir an t-Athair am Mac gus an saoghal a shàbhaladh.

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

For optimist readers- http://bit.ly/2xIBDi9

LET’S SHAKE IT UP A BIT- And do the fraud follies first this week..

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. Husband and wife duo John and Diane Sink of Cheyenne, Wyoming plead out this week to $6.2M in Medicaid fraud. Their charge? Bogus group counseling bills for sessions that included coloring, karaoke, eating at restaurants and shopping. Nagy Mohamed Abdelhamed of York, PA got popped this week for member fraud (we are seeing more of these- is it more frequent, or just less taboo to talk about?). Mr. Abdelhamed’s case appears egregious – he received $1,124 a month in social security disability bucks and collected $30k worth of Medicaid and SNAP benefits in 2018. Problem is, when he applied for Medicaid (in 2014) he only listed $1k in cash assets, no monthly income and no property. Well- he owned a gas station, a Mercedes Benz E350 and has loads of dough in the bank ($58k at time of writing). Timing? He sold the gas station for $172k in the same month he applied for Medicaid. Richard Quitoni of Middletown, NY was charged with a $200k Medicaid fraud. Mr. Q submitted false claims for cab rides for Medicaid bennies, including some doozies for $50 tolls (they’re not that high anywhere in the Big Apple). Mi Ran Yu of Anchorage, AK was sentenced to 8 months in the slammer this week. Her crime? Stealing $90k using false personal care assistant claims. Aleah Mohammed of Queens used her multi-location pharmacy biz to steal $7.9M by submitting false claims to Medicaid (and Medicare). The bogus scripts were either not dispensed to patients, prescribed as claimed or medically necessary. Sonjay Fonn and fiancée (they’re practicing for husband-wife fraud capers) Deborah Seeger of Cape Girardeau, MO stole $1.6M from Medicaid (and Medicare). This one’s fun- Sonjay did spinal fusion surgeries and ordered all his spinal implants from lovey’s DME company. Problem is, lovey got 50% commission on all sales. Lovey then took the Medicaid bucks and bought her handsome prince a yacht and construction projects. John Bradley of Oklahoma City got 8 weeks in jail for stealing $180k in Medicaid bucks. He submitted a slew of false claims for counseling his niece and nephews. Health Management Associates (the hospital chain, not the consulting firm) will pay $260M to resolve claims it paid kickbacks to docs so they could rip off Medicare and Medicaid by ordering unnecessary tests and increasing admits from the ED.

Mr. and Mrs. Sink, you win this week’s award with a respectable $6.2M Medicaid fraud! Taxpayers, you lose…Total tab in this paragraph is around $278M by my count. Work harder, taxpayers – someone has to pay for all this fraud!

 

OK, NOW SOME QUICK NEWS HITS- For all you fraud junkies, was that like eating dessert first?

MRS VERMA DEFENDS WORK REQUIREMENTS – Seema spoke at a conference in D.C. yesterday and let folks know CMS is maintaining its ground on this, despite all the pearl-clutching.

SHE ALSO LET MCOS KNOW A BIG OLE’ MICROSCOPE IS COMIN’- Clients (and anyone who has been around me the past few years) know I have been saying this is coming since the Mega Reg dropped. An MLR-audit is a natural conclusion of the MLR floor, and it will give CMS a simple way to take back cash.

OREGON CONSIDERING NON-COVERAGE OF NEXT-GEN SEQUENCING TESTS– These are tests used in cancer treatment. Medicare just covered it, but OR Medicaid is studying whether the tests are ready for prime-time just yet. The latest report from the OR Medicaid committee studying effectiveness has a clear non-coverage recommendation. Analysts are watching this one because it could be a model for other state Medicaid programs concerned about the costs of these tests.

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 (marvel at the changing of the seasons) 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: Na auina mai e le Tama le Alo e laveai le lalolagi.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2O1xKhv

For optimist readers- http://bit.ly/2O1y5kh

 

IOWA PER-MEMBER MEDICAID COSTS TRIPLED IN SIX YEARS- Luddite MCO-bashers think it’s the MCOs’ fault. You guys may want to look at the impact of a little thing called taking the “expansion” money as well. The costs of the newly-eligibles surprised the heck out of all of us in every expansion state.

ONE REASON MAINE EXPANSION COULD GO THRU DESPITE LEPAGE’S PROTESTATIONS- It’s a state plan amendment, not a waiver. So the state is basically saying “can we please follow existing law” vs “can you give us permission to get an exception to the law.” Good catch by Michael Shepherd @ Bangor Daily. Roundup readers know all about Mr. LePage. After years of successfully blocking expansion, his agency finally submitted a request to CMS for it- with a catch. LePage sent it along with a memo that said – hey please don’t approve this thing.

SUPER SECRET OHIO PBM REPORT A DUD- Well it ended up being “heavily” redacted, anyway. A judge had considered releasing the report, rich with inside scoop on CVS drug pricing, in all its unredacted glory.

CMS APPROVES 6 NEW FINANCIAL EXPERIMENTS FOR 2019- The Big House approved a new set of APMs (Alternative Payment Models) for next year. MA ACOs, OH episode-based payments, TN retro-episodes, and 2 Washington MCO-based projects.

DEMS TRY TO SUBPOENA CMS DOCS ON WORK REQUIREMENTS– They say it hasn’t been thought-through enough, and inquiring minds in Congressional Lefty Land want to know (do you remember the old National Enquirer tag?). Two of our modern statesmen-luminaries, Elijah Cummings (D-MD) and Raja Krishnamoorthi (D-IL) are leading the subpoena charge. They claim the impact of work requirements on Americans is not being vetted, and they want to see projections, spreadsheets, etc. (keep in mind dear readers, they don’t really care- its all for the cameras. Cummings is set to easily be a part of the “Blue Wave” this November. And while Cummings will probably never lose in ultra-blue MD ((he took 75% of the vote last time)), Mr. K is not as safe and needs to appeal to his Big Healthcare industry buddies, who account for his largest campaign donors by far). Back to the story, though- if we can now subpoena CMS docs for policies impacting Americans that we don’t agree with (apply the “that” either to the policies or the Americans, reader choice), I would love to see the analysis done about 9 years ago on the impact of ACA on Americans. How many Americans with non-Medicaid coverage would lose their coverage? How many Americans would be priced out by absurd deductibles and premiums? How much will the taxes need to go up (i.e. the impact on taxpayers)?

 

CONGRATS AND WELCOME TO KEITH WISDOM- He’ll be the new CEO of Aetna Better Health in KS. Aetna was a recent winner in the MCO awards, and Keith will be the first Aetna KS CEO.

 

OREGON SOS ASKING FOR MONEY TO AUDIT MEDICAID – Sec. of State Richardson wants about $780k to staff up an audit team to figure out just what the heck is going on in the Medicaid program.

 

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- er, not so fast. Not enough time/ space this week, dear, dear fraudsters. Get your fix in the twitter feed. (There’s some big ones in there- I’d say at least $22M in total provider fraud, and a dee-lish $200k member! fraud).

 

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 mums, soon) 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: Otets poslal Syna, chtoby spasti mir.

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

For optimist readers- http://bit.ly/2CUKwu5

4,353 ABLE-BODIED, WORKING AGE ARKANSANS DECIDE FREE HEALTCHARE IS NOT WORTH WORKING (OR VOLUNTEERING) 20 HOURS A WEEK- That’s how many AR Medicaid bennies got kicked off last week for failing to meet work requirements. Assuming pmpm of around $200 (typical for healthy, middle-aged Medicaid bennies), the state just saved $10,447,200 by giving the members a voice in whether the coverage was worth it to them. The flip side is 83-90% (depends on whether you count the denom of those subject in month 1 vs current) of AR bennies met the requirement or were grandfathered in. There are also 1,000 bennies who did not have a job before who chose to go out and get one to keep the coverage. Resistors- Commence name-calling, pearl-clutching, et cet era.

EXPANSION STILL NO DICE IN BAMA- The Good Guvn’r Kay Ivey re-iterated this week that Alabama will not be pursuing expansion any time soon. She seems stuck on this whole “you have to pay for it” silliness. Maybe she hasn’t heard the magical incantations about its free federal money? Or the wise counsel to ignore other tales of woe from expansion states that got shackled to crippling Medicaid debt? Quick, someone call Mrs. Ivey and tell her she simply must take the “free” money.

HEAD OVER 1 STATE EAST, THOUGH- And Stacey Abrams (Dem gubernatorial hopeful in Georgia) is promising Medicaid expansion “is the only answer to Georgia’s challenges.” I must say her background is interesting.. a career in finance and tax law. If anyone can figure out how to get more Medicaid moula, surely it would be a tax attorney. But wait a minute, there’s more- according to an op-ed she wrote for Forbes in the spring, she owes $50,000 in taxes and has outstanding credit card and student loan debt of $170,000. I must say- Mrs. Abrams is uniquely qualified to set Medicaid policy. All she has to do is take her current personal finance skills and scale it up to the level of a state agency. Onward and Upward!

OK, I KEEP READING ABOUT ABRAMS, AND IT JUST GETS BETTER- She is also a romance novelist. I kid you not. Titles include “Hidden Sins,” Secrets and Lies,” The Art of Desire,” and “Deception.” Here is a link to her Harper Collins author page if you don’t believe me. I am unable to resist the temptation to personify Medicaid (as the male interest, a public health Fabio, if you will) in one of her novels. “I looked across the meadow, and the Budget Deficit was staring at me. A look of voracious desire burned a hole into my bones. As he ran to meet me, all I could do was smile and think “Medicaid expansion.” The wind blew through his hair, and we embraced. Mr. Budget Deficit and I were a match made to be. Some might even say, a Federal Match.” FMAP- get it? Ba-dum-bum-bum. Please, please, please Georgia voters- elect this gem. She will give all us writers 4 years of complete silliness to write about.

WE WERE JUST KIDDING ABOUT MORE PRIOR AUTH RULES- Says the NV Medicaid agency. NV Medicaid spending doubled when in expanded, and regulators are desperately looking for any tools to help control costs. They wanted to put more prior auth around certain mental health services to slow down utilization – but providers were loud enough that the state decided not to. Also I think maybe there was a go fund me that raised $10M that said they would NOT call agency officials mean names if they reversed the decision. Or am I getting that confused with some other state?

THINGS IMPROVING IN CT NEMT- We reported previously on the challenged Veyo contract in CT. Looks like there have been significant turnaround efforts (re-training call center reps, improved provider outreach) and the call center wait times are down from 5.5 mins to 2.8. I’m loving the terms and conditions on this contract though- Veyo got $52M in year one of a three-year contract. Lots of terrible press in past few months about service quality, so they have been fined. Total fines Feb. to Sep- $13,500. You can’t make this stuff up.

REMEMBERING 9/11- That’s still ok to do, right? This week we hit the 17^th anniversary of this evil attack on U.S. soil. I remember exactly where I was when it happened (living on a friend’s couch) and most of that day very clearly. Have a 9/11 story? Would love to hear it sometime. Send a note. Give a call. Too young to remember it? Here’s a recording of CNN coverage as it happened.

 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. Haydn Thomas and Catinia Farrington of Raleigh, NC plead guilty to stealing $4M Medicaid bucks using their mental health counseling business to submit false claims. Francis Steen and Alicia Sanders of Savannah, NY got caught in “Operation Find the Dough” (that’s the real name local investigators gave their op, and I love them for it). This dynamic duo provides for us one of our rare member fraud cases (rare in that they got caught and were above our $50k minimum for Roundup appearance, technically). It’s a pretty cool list of thieveries for these two- $23,957 in SNAP benefits, $676 in Low Income Home Energy Assistance Program (LiHeap- bonus points!), and $44,594 in Medicaid benefits. Centers Plan for Health Living in Staten Island agreed to pay $2M to double dog promise it did not steal Medicaid bucks by enrolling non-eligible members and then sending Medicaid the bill. Haydn and Catinia – You win! Taxpayers, you lose – about $6.1M based on the ones we showcased today. Work harder!

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 (get a surprise puppy and forever be a hero in the minds of your children) 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: Tatăl la trimis pe Fiul să salveze lumea.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2wNmryN (1989)

For optimist readers- http://bit.ly/2wLmsDv (1976)

 

POISON PILL IN MAINE- LePage’s administration finally submitted an expansion waiver request this week to CMS. But the Good Guvn’r asked CMS to deny it. LePage sent Veerma a letter, with the gist being – “Hey, a lefty judge forced us to submit this waiver app, but we ain’t got no cash for it. So best to just shoot it down. Wink-wink. Nod-nod.”

SD BALLOT EXPANSION INITIATIVE LOSES KEY BACKER- State Rep David Moore was a proponent of expansion in SD when it included a sunset provision / escape clause if it put SD on a runaway, break-the-bank spending path (like it has in most states that took the “free” money). Now that activists have put full-on, no-way-out expansion on the ballot in November (I-185; not an interstate but rather how they name their resolutions they vote on come election day), Moore has come out against it in a pretty high-profile op-ed. Seems like some other op-ed in the NYT overshadowed this one. I missed the NYT one. Can someone tell me the name of the person that wrote that one?

ASTRAZENECA TO PAY TX $110M TO DOUBLE-DOG PROMISE IT DID NOTHING WRONG- The Lonestar state should have held-out for triple-dog level money. AstraZeneca got caught marketing Seroquel and Crestor off-label. For Seroquel, they worked to get docs to feed it to teenagers, before it was approved for the hip kids. For Crestor they downplayed diabetes risks.

WHY CAN’T COUNTIES IN NY JUST CONTINUE TO PAY BALLOONING MEDICAID COSTS AND SMILE LIKE EVERYBODY ELSE? Well for one reason there’s a new report out reminding county managers how much they must chip in and how big the NY Medicaid behemoth has become. Its now a $70B budget – just for Medicaid; bigger than some state’s entire budgets- and counties have to pay $7.6B of that. And it used to be worse before Pataki and Cuomo put in hard caps on what counties pay.

RELATED TO THAT LAST STORY– NY Medicaid enrollment has grown 57% over the last 10 years. There are now 7M enrollees, which translates into about 36% of all state denizens.

CONGRATULATIONS TO CAROL, BUT MORE SO TO KY– Carol Steckel will take the helm as KY Medicaid Commissioner. She’s one of the absolute best Directors our little world has seen, and I have lost count of how many states she has headed up.  Carol, Congrats! KY team – you made a great choice!

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. John Durmon of Warren, AR was charged with stealing $185k in Medicaid dental bucks. Some good nuggets in this one – he billed for 2,557 x-rays for 85 patients over a 1 year period. That’s 30 x-rays each! Margaret Williams of Anchorage stole an estimated $7M using her nursing homes. Flamingo Eye (that’s the name of the nursing home chain- maybe it made you think of warm places while you were in her crappy nursing home in Alaska?) was used as a rev-max scheme for elderly and disabled members. Waveny Blackman of National Harbor, MD plead to stealing $9M Medicaid bucks using fake patient IDs to bill for bogus medical supply products. Vincent Njong of Silver Spring, MD plead guilty to stealing $66k for bogus billings as a personal care aide (with $66k you just barely made the floor to get included in the RoundUp, Vincent – try harder when you get your billing ID back. Which we all know you will in a few years). Margaret, you win hands down! Taxpayers- you lost $16.3M this week just in these stories that made it the news. You better work hard and smile just thinking how you are helping pay for all this fraud. Somebody’s gotta pay for it.

 

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 (start chopping firewood. I predict a real winter this year) 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: Pitā nē jagata nū bacā’uṇa la’ī putara nū bhēji’ā.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2LKpRI9

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

 

I WILL BE AT MHPA 2018 IN OCT., WILL YOU? You can check it out here – http://bit.ly/2M4KRhY

If you are going, please let me know. I absolutely love to meet RoundUp readers in real life.

MAYBE LONESTAR STATE PULLING THAT MCO RFP RECENTLY IS MAKING MORE SENSE? TX providers gave legislators an ear full on Wednesday. Many tales of provider woe from meanie MCOs, including delayed payments, more paperwork and tighter utilization control. Providers also complained that there are not enough agency staff, and the program is underfunded. This is an easy fix, guys – more money! Duh, Wilberforce.

MISSOURI PHI BREACH FOR 19,750 CHILDREN- WellCare sent letters reminding kiddos (or their parents) about the need for well child visits- but they sent them to the wrong addresses. Seems to be a recurring problem, with a similar breach involving 1,223 member letters last year.

ADD THE MOUNT RUSHMORE STATE TO LIST OF THOSE ASKING FOR WORK RQUIREMENTS- South Dakotans have spoken (through their duly elected representatives, unless of course Russia swung recent SD elections, too. You never know. I was talking to John Stewart at an Antifa potluck he and I were both at last weekend, and he says the Ruskies swung SD. And I like to get all my political analysis from celebrities. Totes) and they want CMS to allow work requirements for their Medicaid program, too.

 NEBRASKA JUDGE OK’S MEDICAID POLICY BY BALLOT; MEDICAID DIRECTOR ROLE NO LONGER NEEDED- Two state lawmakers had tried to head it off at the pass, but no dice. A judge ruled this week that Medicaid expansion can go to the ballot. Hey voters- which DRG grouper do you think we should use next year? Also, we need to update our CMS-34 reports to pull down the additional funds needed. Do you think we should check box 1 or 2 on section F? Would love your opinion…Cuz y’all are totes awesome Medicaid geniuses.

 TRYING TO DEAL WITH OPIOID CRISES IN OREGON IS TRICKY- New plan to make current chronic pain opioid users taper down to zero over 12 months is not without its detractors. That is a best practice, by the way (at least based on some of the research we are using in our upcoming Understanding the Opioid Crisis online course).

 TN HOSPITAL SUES STATE SAYING IT FAVORS MCOS OVER PROVIDERS- Erlanger Health System in Chattanooga (man that’s a fun word) has sued TN over payment rates to hospitals. Looks like a 2007 law requiring MCOs pay the average in-network rate for Medicaid ED visits may be getting interpreted to be the lowest in-network rate instead. Here’s my question – How do the hospitals that’s suing know any of the rates besides their own? Isn’t that secret-sauce, MCO/provider contract stuff?

FL MCO AWARDS COURT CASE STILL GOING- I thought this was over, but the AIDS Foundation plan that lost out, and the South Florida Community Care Network are still pushing for either a new RFP or new awards (for themselves). You know the old- “do the right thing or favor us. Whichever one comes first, we’re cool with as long as it favors us.”

CA MAY PAY FOR TELEHEALTH FOR SUD TREATMENT- Perhaps seeing IL do a similar thing, CA Good Guvn’r Brown is planning on signing a law that will allow for substance abuse counseling sessions via telemedicine (think a Skype session with your therapist).

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. East Mental Health of Roanoke, VA may get off this time due to prosecutors not meeting a discovery handover deadline in this $45M Medicaid case (there are 3.5M documents to wade through). Christopher East (the owner) is charged with 73 counts of tomfoolery, including making up claims and records needed to nab the Medicaid bucks. Helen Balding and Robin Raveendram – who operated the fairly high-profile Arkansas Preferred Family Healthcare scam – were arrested on Medicaid fraud charges in the past few weeks. Looks like Robin was the brains behind the operation, instructing employees VIA EMAIL to forge $2.3M in claims. Michael Gaines of Baton Rouge (Red Stick for all you parents of curious children) was collared as part of the ginormous federal healthcare fraud sweep recently (along with 20 other defendants in the town). He stole about $2M as a social worker by submitting bogus claims for group therapy for students. Matilda Prince of Mineral Bluff, Georgia was sentenced to 3 years for stealing $1.2M from both Medicare and Medicaid. She billed for optometry/ophthalmology services never provided. Melissa DeLap of Jefferson City, MO was sentenced this week for stealing $106k by falsifying personal nursing claims for 4 Medicaid members. One of the people she supposedly provided care for died in Sep 2016 but was not even reported missing until April 2017. Mr. East, your strategy of “drown em’ in documents” put you over the top and you win this week! Taxpayers, you lost about $51M just in these cases that made it to the news. Keep working hard!

 

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 (plan your winter garden/greens) 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: Pai enviou o filho para salvar o mundo

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2MLMm40

 

For optimist readers- http://bit.ly/2M48HKs

 

CMS SPEAKS ON DEMO WAIVER BUDGET NEUTRALITY- CMS rolled out new guidance this week on how states can prove 1115s are budget-neutral. Looks like there hasn’t been much tracking of this until now (and not even a formal calculation method if I am reading the stories right). Moving forward, these things may actually get evaluated for whether the demonstration waiver “demonstrated” its “innovation.” Good luck to all the DSRIP programs out there. If you are opposed to fiscal responsibility and transparency, I recommend fighting this one with all you’ve got.

  

OKLAHOMA TO PAY FOR DRUGS THAT WORK (AND NOT PAY FOR ONES THAT DON’T)- OK is now greenlighted by the federalis to negotiate prices with drug manufacturers based on whether or not super-expensive drugs actually do anything to help the patient. 1^st contract is with Alkermes for a schizophrenia injectable. Its an interesting approach – price keeps going down as long as the prescription keeps getting refilled (the metric for whether its helping, I guess).

  

HOSPITALS STAND TO LOSE LOTS AND LOTS OF CASH IF KY MEDICAID EXPANSION NIXED; COME UP WITH THEIR OWN PLAN TO FIX IT- Hospital execs in KY have put together a “group” called Balanced Health of KY. It’s big idea? Wait for it… Up the provider-tax magic money scheme to pay for expansion if the whole KY vs Lefties court case doesn’t allow expansion to keep going. For new readers, these schemes allow hospitals to happily pay a “tax” that then gets matched with federal dollars, which then go back to the hospitals. But of course, its mean-spirited to question the ethics of this (like GAO and other investigators have been doing for decades).

  

ADD IL TO LIST OF MEDICAID REIMBURSEMENT FOR MH/BH TELEHEALTH- The Good Guvn’r Rauner just signed a bill allowing Medicaid to pay behavioral health providers for telehealth. Probably easier now that IL got $2B from feds to address the opioid crisis. IL already allowed psychiatrists and FQHCs to get paid for telehealth; the new bill opens up payment for clinical psychologists, social workers, anps and other mental health professionals.

 

“MEDICAID IS THE ONE FOR OLD PEOPLE, RIGHT?”: SENATE WANTS TO HEAR FROM CMS ABOUT FRAUD- Senators (those wise old, Medicaid policy experts making all the big funding decisions) heard from Ms. Veerma on Tuesday. They were particularly interested in her thoughts on fraud in the program, as well as insights into possible recoveries against TX for its uncompensated care financing scheme (prob a magic-money/provider tax scheme but I don’t have the details). Senators also heard from GAO officials the same day. GAO shared insights from its recent reports about CMS not having enough data to perform effective fraud monitoring. Coming out of the hearings, all Senators unanimously agreed to with-hold 10% of federal funds until somebody actually did something about fraud. Just kidding! Everyone agreed that Medicaid fraud is clearly Mr. Trump’s fault and should be included in the scope of Mr. Mueller’s investigation. #Impeach! #Resist! #1984!

 

GRANDMA GOT RUN OVER BY A PRIOR AUTH SYTEM: AFTER COURT BATTLE OVER WHO IS FINAL SAY ON COVERAGE, UNITED HEALTHCARE HAS TO BUY WHEELCHAIR FOR GRANDMA- UHC Iowa repeatedly denied a nursing home resident a request for a special wheelchair after 3 court cases where it took the unusual step of fighting it. Anyone know why? Seems like not worth the PR, but maybe I am missing something…

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph-  Not enough time this week, my dear, dear fraud junkies. Check the twitter feed for a lot of shared cases, though (at least 20 cases).

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 (get up early – the cool morning breezes will remind you of things forgotten) 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: Ojciec posłał Syna, aby zbawił świat