Category: Clay’s Weekly Medicaid Roundup

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2M48HKs

For optimist readers- http://bit.ly/2M4seul

(There is somewhat serious talk of a Mostly Medicaid sing-along at the MHPA conference in DC in October. Sign up here and send me a note if you want to join the band – http://bit.ly/2M4KRhY)

 

FIRST A SHOUT OUT TO ALL MY NEW i2i PEEPS- Had an amazing time in PHX (even if it was 147 degrees, Celsius) with the i2i team this week. Got to see all the really cool, market leading things this team does in the Medicaid space. Check out their website here – https://www.i2ipophealth.com/

AND WE’RE OFF! / PINCH ME I’M DREAMING- The NC managed care RFP was released yesterday. After so long expecting it, its hard to believe its finally here. Know who I really feel bad for in all this? The RFP reviewers. Best I know EVERYONE is bidding on this thing…

HOW MUCH IS TOO MUCH? The Ohio Medicaid saga around spread pricing by PBMs is ramping up. Optum joined the CVS lawsuit this week to keep the secret sauce secret. State officials want to release data on how much the PBM is charging beyond price of drugs; CVS and Optum don’t like that none too much. Stay tuned. Will cover on Monday’s news show if you can join.

NEW MANAGED CARE REGS UNDER WAY? In addition to possibly revisiting the MegaRule itself, CMS has started the review process for new MCO regs around provider enrollment. OMB apparently got it on Aug 3.

LONESTAR STATE GETS $110M FROM RX SUIT- AstraZeneca will pay out a truckload of cash (that’s nearly enough to pay off Iran in the middle of the night- oh wait that was $172B….) to Texas to settle allegations it marketed Seroquel and Crestor for off-label indications to docs. They apparently were already in trouble for similar shenanigans when they did this particular bit of Double-Plus UnGood.

 

YOU KNOW THERE’S A LOT OF WORK TO GET READY FOR EXPANSION. NOW IF ONLY CMS WOULD APPROVE IT- Regs have to be updated, systems prepared, sister agencies brought on board. TONS of work (check the twitter feed for an article on the efforts to get ready for expansion in VA). You just don’t think about these things when you view “expansion” as a magic spell cast over the land.

 

ANOTHER STUDY REFUTING THE CLAIM THAT MOST MEDICAID EXPANSION BENNIES WORK ALREADY- A nonpartisan (Lefties can claim that word for their think tanks, so why can’t Righties?) Idaho think tank says bah humbug to the coordinated studies showing work requirements won’t matter based on the dubious claim that most subject to the requirement are already working. When the Foundation for Government Accountability (who the heck really wants that anyway?) looked at Illinois, it found 70% of bennies who could work were not working. FGA also estimates that nationally 6.8M (out of 12.4M expansion bennies, who likely could work) are working already.

 

FL MCO AWARD PROTESTS SETTLING DOWN- A FL judge has ruled that Best Care Assurance has no standing in the protests, because it didn’t weigh in when Molina protested. Gotta play to win, folks.

 

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. Shahrzad Haghayegh-Askarian of Norwell, MA was indicted this week for stealing $200k by billing under another dentist’s name. She’s another 2-time offender, paying out $300k in 2015 for other fraud charges. LaGracia Burnett of Haverford, Delaware was convicted this week of $211,492 in Medicaid fraud. She was a traveling therapist and got paid using false claims for behavioral health services in multiple counties. Thomas J. McLaughlin and Joseph Campione of North Andover, MA have to pay back $612k to Medicaid patients that they charged for Suboxone (so they got paid twice- once by Medicaid and again by the patients). Elena Kurbatzky operated a home care fraud AND she herself was a Medicaid bennie. This may be a first. In addition to the cash she stole from MA, she also hid her $2.3M income so she could herself get Medicaid benefits. You go girl! I think Ms. Haghayegh-Askarian is the clear winner. Her perseverance in continuing to steal even after her 1^st conviction should inspire us all. Taxpayers – make sure to work extra hours this weekend. We have at least $1.5M to make up for with these cases alone.

 

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 (cut down those browning sunflowers if you planted them; or let them dry in place and drop their seeds. According to my hunter friends, this will bring doves.) 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: پدر پسر را فرستاد تا جهان را نجات دهد

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2KqKJn8

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

 

THIS IS NEW- As part of an investigation into a plane crash in AK, Medicaid Director Brodie has had to clarify that Medicaid does not pay for flying groceries and building materials when you happen to be going to a Medicaid visit. Basically the $90M AK NET program uses planes, and a Medicaid bennie en route (with some extra baggage, apparently) was on a plane that crashed recently. She and her 2 year old are ok; the pilot died.

UPDATES ON 2 FL CONTRACT PROTESTS- The AIDS Healthcare Foundation is still ticked about losing its contract in the latest round of FL MCO awards. Protests were planned for Thursday to blame the Good Guvn’r Scott. Scott says the plan is just a private sector business that is mad their revenues were awarded to another plan. Also in FL- Argus Dental and UHC both withdrew their protests of the latest MCO awards. Their protests were related to the new scope of dental services in FL Medicaid, touted as the “broadest dental package ever available to Florida Medicaid recipients.” Congrats to our friends at Liberty Dental, DentaQuest and MCNA Dental who all won in the recent awards!

GOOD NEWS OUT OF OHIO RE OPIOIDS- CareSource announced this week that opioids scripts to its members have decreased 40% in the past year and a half. The MCO is working to reduce it 50% by the end of 2018.

KAISER DROPS RURAL COLORADO MEMBERS TO INCREASE ACO SUCCESS ODDS- About 2,500 members in the northern, southern and mountain areas of CO were dropped by Kaiser Permanente this week. Kaiser will continue getting cap for the 670,000 members in easier-to-serve areas of CO, however.

 NH SCHOOL-BASED SERVICES PROGRAM TOUCH AND GO- NH lawmakers passed a funding bill last year to provide speech therapy and other services in schools to all Medicaid-eligible (not just those enrolled) kids in schools. Recent changes in federal funding rules allowed for an additional bump of $28M to the program. Latest news out of Concord suggests program officials are running behind on implementation work, and school starts in just a few weeks.

 NATIONAL EVV REQUIREMENTS DELAYED-  President Trump signed a law this week that delays the much-anticipated electronic visit verification (EVV) components of the 21^st Century Cures Act. Major requirements to include EVV were set to begin Jan 2019 (new dates are in 2020). Disability advocates have opposed requirements related to GPS tracking of homecare workers and celebrate the delay. Overall, this is a loss for those of us concerned with reducing the egregious fraud in homecare services.

 

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. Salwa Albayati of St. Louis was charged for her role in a personal care services scheme. She and her caregiver billed Medicaid $700 every 2 weeks, including times when Ms. Albayati was in Europe and the Middle East. Salwa took a $420 cut out of every payment. Total bill since 2011 is $241k. Compassionate Homecare operators Carol Anders and Ryan Santiago of Raleigh, NC were ordered to payback the $585k they stole from Medicaid (and another $2.5M in penalties). Pretty much a typical services-not-rendered, not allowed per policy scheme. Wossen Ambaye and Haimid “Mookie” Thompson of Buffalo, NY stole $1.2M using an NET scheme. Lots of billings for trips that never happened or were not in accordance with Medicaid policy. Gena Randolph of SC can make the dead speak, at least according to her Medicaid claims. Randolph was convicted this week for stealing $2M using bogus speech therapy claims (including services for members who were dead). Bonus – She was also convicted of Medicaid fraud in 2012. (Special thanks to Mark for sending this one in). Mustak Vaid of Brooklyn was sentenced to 18 months in the slammer for serving as the face of a 6-clinic fraud scheme operating on Medicaid cash. Vaid and Aleksander Burman ran clinics that stole about $30M from Medicare and NY Medicaid. Features of the scheme include falsifying medical records to get around pesky medical necessity requirements, hiring corrupt doctors to pose as owners of clinics and billings for supplies and services never provided. Ms. Randolph, you win this week’s award! Your perseverance and can-do attitude as evidenced by 2 Medicaid fraud convictions in 6 years put you over the top. Taxpayers, you lost $32M on the schemes uncovered this week.

 

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 some weeding) 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: پلار زوی ته واستول ترڅو نړۍ خوندي کړي

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2K6c8L6

For optimist readers- http://bit.ly/2K1pTKH

MEDICAID ROLLS KEEP DROPPING IN FL- Current estimates show about 500k less bennies on the roll for this SFY compared to last. One theory- once the state started using Equifax to link income data to Medicaid eligibility, a huge amount of bennies who made too much money were dropped.

WORK REQUIREMENTS IN MS? NOT IF ADVOCATES HAVE ANYTHING TO SAY ABOUT IT– The Tupelo protest machine is starting up. Agency officials submitted a plan for adding a Medicaid work requirement, but groups like the Mississippi Health Advocacy Program and Community Catalyst have begun official opposition in recent weeks.

TREASURE STATE SURPLUS MEANS MORE TREASURE BACK TO PROVIDERS- After some initial confusion over whether the agency was following court orders to reinstate nursing home payment rates, The Good Guvn’r Herbert announced full rates for the huge facility-provider lobby (er- I mean nursing homes) were back on. How, you ask? MT apparently has a revenue surplus. The extra cash will be used to undo a 2.99% rate cut to nursing homes and for mental health case management funding. About $45M is getting pumped back into the Medicaid budget.

 THE GRANITE STATE WANTS TO UP PROVIDER PAYMENTS, TOO- Seems the migration of about 50,000 Medicaid members from a private commercial program (exchange-subsidy program maybe)? to Medicaid managed care will cause substance abuse providers to see about a 50% drop in their per diem. Lawmakers met this week find another $7.5M to avoid the drop in provider revenues. New Hampshire currently has a $22M surplus- making the SA providers whole would take about a third of it.

NEVADA SET TO REDUCE ALLOWED NUMBER OF COUNSELING SESSIONS- Medicaid members can currently get 26 visits per year. If a new policy designed to combat fraud by mental health providers goes into effect, the total allowed visit will drop to 3 per year – before the provider has to submit more paperwork to authorize additional visits.

STRONG GROWTH REPORT FOR ANTHEM- Highlights include: 23% YOY revenue growth, with operating revenues now at nearly $23B. A drop of about 880k lives was attributed to shedding exchange plans. Class, remember: you make money on Medicaid (you pretend to assume risk); you lose money on exchanges (you have actual risk). Reports also show an expected increased emphasis for Anthem on Medicare opportunities.

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. Waveny Bleckman of D.C. pled guilty this week to stealing $9.8M in Medicaid bucks using his DME company. Georgia Phillips of Brownsville, TX was ordered to pay $500k back to Medicaid after stealing taxpayer dollars (Medicaid funds) using her speech pathology clinic. Slow week for Medicaid fraud (I’m sure that these 2 cases were all the fraud that happened, so no worries taxpayers!). Waveny, you win hands down!

DON’T FORGET TO BOOK YOUR OCTOBER TRIP FOR MHPA- I will be there again this year. Should have discount code for MM readers soon. Check out agenda here – http://www.medicaidconference.com/conference/program-tracks

 

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 unusually cool weather) 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: Atate anatumiza Mwana kuti apulumutse dziko lapansi

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2LyE8IO

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

GIVE A WARM WELCOME TO THE NEW IL MEDICAID DIRECTOR- Patti Bellock took the helm 7/11. Welcome!

LET’S TAKE ANOTHER LOOK AT THIS KY THING- Undeterred by the litigious slowdown from a few weeks ago, KY officials are revising and resubmitting their work requirements waiver to CMS. Keep in mind the judge did not rule work requirements to be the problem- but that CMS did not do a proper review of the impact. CMS has announced a 30-day comment period on the waiver. If you need boilerplate on how the sky will fall and the world will end if the waiver is approved, I can send you a few links to think tanks who are actively coordinating propaganda – er, I mean comments / responses “curated” to make sure the “public” opinion is heard correctly. I am sure it will be balanced.

 

LAST FRONTIER STATE ASKS FOR $15M BACK FOR OOPSIE PAYMENTS- Seems like the AK legislature passed a 10% cut to Medicaid (that’s called a law when its passed by the legislature), but the agency forgot to make it happen. This has been going on since October, so now the agency has paid out $15M illegally (that’s what its called when you do something in violation of a law) to providers. Now its sending out pretty-please-send-the-money-back letters to providers. More than a few providers are saying they’ve already spent it and can’t afford to pay it back. Somebody call Bernie. I know he’s been working on College-For-All and Healthcare-For-All. Surely he’s solved it by now.

DESPITE CLAIMS BY ADVOCATES THAT MOST MEDICAID BENNIES WHO COULD BE WORKING ALREADY ARE- A new report in Illinois shows that 70% of able-bodied Medicaid expansion bennies are not working.

EARLY NUMBERS IN ON BENNIES FAILING TO MEET WORK REQUIREMENTS IN THE NATURAL STATE- A little north of 7,000 members did not report enough hours in June to be compliant with the new rules in Arkansas (there are another 18,000 subject to work requirements but who don’t have to report hours due to other exemptions). About 450 members did meet the requirements. Those who missed the mark in June could lose coverage if they go 2 more months without working.

 

THE MOTHER OF PRESIDENTS STATE PAYS MOTHER OF ALL RX MARKUP FEES- An early look at the report looking into how much Medicaid money CVS Caremark (the pharmacy benefits manager, or PBM) kept in Ohio shows about $224M staying with the middleman (CVS) after pharmacies were paid. Not sure if that’s a big deal or not? According to the report the OH CVS markup is 3x what CVS normally gets in other markets. This kind of reminds me of 340B providers not passing on savings to poor patients, but that’s another kettle of fish…

ADD IDAHO TO THE LIST OF STATES WHERE VOTERS ARE ALL NOW MEDICAID DIRECTORS- Expansioners have certified the number of signature required to get expansion on the ballot in November.

ANOTHER TROUBLED NEMT MARKET IN THE NEWS- We covered challenges with Southeastrans service in Indiana on the show this week. Looks like Veyo continues to struggle in Connecticut. Recent reports include high profile meetings with healthcare providers and advocates who are voicing complaints over missed rides. In their defense, Veyo delivered 364,000 trips in May and only 478 complaints were filed (less than ½ of 1 percent of rides). Some of the complaints get into how long providers have to be on the phone to resolve issues, and whether drivers are showing up with appropriate vehicles (i.e. wheelchair accessible).

 

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. There was a huge, national Medicare/Medicaid fraud dragnet in late June and most of the stories out now are from that. I will hit the highlights from that sweep: Health Quest Systems of NY will pay $14.7M to double-dog promise they are not guilty of upcoding E&M visits paid for Medicare/Medicaid. Brent Clarke of PA will pay $360k for his role in a medically unnecessary services scam. Mayura Kanekar of Queens and 12 of their (not sure if that’s a male or female name) closest criminal buddies were charged with stealing $163M from Medicare and Medicaid this week. Looks like this scam involved 5 physicians, 3 therapists and 2 pharmacy owners (there’s a high school algebra word problem in there somewhere). “Dr” Abraham Demoz of Oceanside, NY was nabbed (along with 4 of his buds) for his role in stealing $163M in an illegal kickback scheme using referrals to their clinics. Once they got the patients to their clinics, they then billed for lots of physical and occupational therapy. That’s it for the ones from the big national sweep. The biggest one that I think was Caid’ only this week was in MA. Michael Davini of Worchester, MA will go to court over fraud charges related to a $19M scam in which he is accused of money laundering and false bills to MA Medicaid for non-emergency transport. The case says Davini billed for wheelchair van rides for members not in wheelchairs. Mr. Davini – you win (we keep the award Medicaid-specific)! Taxpayers – you lost at least $350M this week by my count.

 

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 (have a water balloon fight, or run in the sprinkler) 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: Faderen sendte Sønnen for å redde verden

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

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

Don’t forget Monday’s Monthly Medicaid News Roundtable show where will cover a lot of these in more depth with the panel. Sign up for free here –

http://www.mostlymedicaid.com/?page_id=3176

 

 Bigger than normal fraud section at end today. Enjoy!

BLUEGRASS STATE MEDICAID REFORM SLOWED DOWN AT THE BENCH- Most of you saw that the KY work requirements plan was stopped by a judge’s gavel last week (an image of king dropping his scepter to note a ruling flashes in my mind). Thank you to all the readers who sent in various analyses and insights. It appears to be a KY-only ruling, in that the judge found CMS did not consider whether this particular request facilitates the “purposes and goals of the Medicaid program.” I invite all readers to read Title XIX of the Social Security Act (which defines Medicaid) and weigh in on what the purposes of the program are. Here’s a link to the full act- https://www.ssa.gov/OP_Home/ssact/title19/1900.htm

My hot take is that SSA defines Medicaid’s “purpose” as a way to give states cash for health care (for the states that want to pay their part of it). Not the lofty insure the uninsured, etc stuff we have come to ensconce in Medicaid mantras some 50 years later. Do I think the judge actually read SSA to compare the request to the “purposes and goals” of Medicaid? Doubt it.

DID YOU KNOW UNIONS GET A CUT OF MEDICAID HOME HEALTH DOLLARS? I DIDN’T – Talk about graft. Seems Dear Leader O gave unions a tidy little bundle of cash under ACA. Here’s how the scheme works: ACA included a rule that allowed states to divert a portion of home health care workers to mandatory union dues. Usually federal regs don’t let Medicaid provider payments go to anyone but the provider, but O made an exception. How much did unions get from this tiny little vig off the ACA pie, you ask? About $200M each year. Plenty to send back in through campaign contributions, etc. Quick lefties – claim the moral high ground somehow. Tell me how this is anything but slimy politics with “healthcare for the poor” as cover.

NEW TELEHEALTH REPORT OUT- Well 2 reports actually (check the site for links / copies in the next few days). Similar results as last year’s info, I think. Telehealth is now defined in most states, Medicaid has better payment than commercial, still struggling to get services that happen while patient is sitting in their living room covered (besides remote patient monitoring- have to go to a provider office that is part of a hub/spoke model for most consults).

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. Rebecca Norris of Frostburg, MD (sounds chilly) plead guilty to nabbing $850k using her Appalachian Wellness Centers to do video-based therapy but billing it as face-to-face. Chin Kim of Bethel, AK has been charged with stealing Medicaid dollars by taking vouchers bennies are given by the state to cover travel costs (flying in to Bethel to get care, hotels, etc) and then submitting them to Medicaid for payment. That part seems ok per rules- it’s the $4k to $57k increase in one month that put Kim on the MFCU radar for fraudulent billings. Dana Trandahl of Butte, MT is charged with billing $74k in services not provided using her counseling service. Galit Levi of Queens plead guilty to stealing $67k in Medicaid benefits by hiding her annual income of $225k. In a very unusual twist, she paid it all back and got a $1,000 fine. Hope In-Home Care of Newport News, VA has agreed to settle Medicaid fraud allegations by coughing up $3.3M (to emphasize their innocence, of course). Charges included false claims for personal care services, falsifying statements of eligibility for members and for prior authorization and billing for services not provided. James Burkhart of Indianapolis was sentenced this week for his role in the American Senior Communities scheme which stole $10M from Indiana Medicaid using an elaborate vendor kickback model. The scheme facilitated multiple frauds by allowing vendors to send higher bills for their services to nursing homes, which would in turn be reimbursed by Medicaid (basically gaming the cost report if I understand correctly). Mom and daughter duo Julie Longton and Leanda Zupka of Norwich, CT will pay $300k back to Medicaid that they stole using unlicensed therapists in their counseling business. Galit – you win! You paid it all back, which never happens. Taxpayers, you lose. Which happens every week (but you better smile and take it, else you’re a big ole’ 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 (cut the grass-but bag it if you have weed problems. No need to put the seeds right back on your lawn) 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: Bubālē chōrālā’ī sansāralā’ī bacā’unubhayō.

Soundtrack for today’s RoundUp pessimist readers-

http://bit.ly/2MySpFq

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

SIMPLIFY THE MATH, UP THE SAVINGS- Pretty entertaining to watch the debate over “savings” of the new Medicaid managed care ramp up in Iowa (I say new, its been a year or 2 now, just seems new since the media keeps tarring and feathering it anew each day). The numbers have been a roller coaster, hitting a high of $232M last year, then dropping to $47M. Now the “savings” is back up to $141M. The New New Medicaid Math is simpler and better, mainly because it shows more savings. Here’s an idea – how about fee for service sucks in terms of quality of care and that’s a good enouch reason to have managed care in Medicaid? Is that good enough to let Iowa move into the 21^st century healthcare system for Medicaid members? Let me know when we start scrutinizing savings estimates of more popular “innovations” like social determinants waivers or health lifestyle / member engagement programs. Ready to have your savings math beaten up every day for 2 years on those?

 

CMS SAYS NAH (READ THAT IN YOUR BEST APPROXIMATION OF BOSTON ACCENT) TO MA- Short backstory, Massachusetts wanted to opt out of the Medicaid Drug Rebate Program because it forces them to pay for whatever drugs are approved on the federal formulary (I’m simplifying). Early analysis suggests MA was hoping to have their cake and eat it, too. They wanted to exclude some drugs in their program, but also keep getting the rebate goodness on other drugs via MDRP. CMS said that is not workable. Sort of the basic way the MDRP functions, folks. Maybe MA will revise the request to opt out of MDRP altogether? Or follow OK, which recently got its plan approved to modify its Medicaid rx program (by adding more rebate deals tied to outcomes of the drugs)?

 

CMS READY TO START CHECKING RATE CELLS- CMS will be doing some verifying of who goes in what rate cell. For non-MCO readers, think of rate-cells as buckets that members get put into. The MCO gets paid different amounts based on the bucket. If Clay is in the 20-25 year old healthy male bucket, the MCO might get $200pmpm. If instead he is in the TANF-SNAP-SSI-DISABLED-ELDERLY bucket, the rate cell would pay out much higher (maybe around $1,200 pmpm depending on the market). From a state perspective, you want to get as many people as possible in the ObamaCare Magic Money bucket / rate cell – because that’s the one feds pay almost all the costs for (going rate of 90% as we come down from the high of ACA expansion coercive fmaps). CMS will now be doing more audits to confirm that enrollees are correctly placed in the pre- or post-expansion rate cells. The agency also announced audits of states like CA that OIG found to be incorrectly enrolling people in Medicaid.

 

HOLY SMOKES BATMAN! UPDATE THE WORK REQUIREMENTS MAP TO SHOW MICHIGAN- I think this is the state that the legislators passed a law that would stop salaries for the Governor’s HHS staff if he didn’t submit a waiver request to CMS for work requirements. Looks like the strong-arm tactics worked (I have never seen anything like this in all my 87 years of doing Medicaid). The bill passed includes terminating the expansion program (people who did not have Medicaid before 2014 or so) if CMS does not allow the state to charge a 5% premium to able-bodied, non-elderly bennies at 100-133% federal poverty level. The gloves are off.

 

CONGRATS TO THE KANSAS MCO CONTRACT WINNERS- Aetna, United and Centene (Sunflower State Health Plan) all won renewals in KS this week. Amerigroup got the boot. Winners – 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.  Susan Britt of Norwich, CT was arrested this week on charges of getting paid $91k for services not provided (she’s a mental health counselor). Felicia Blount and Charlotte Hunter of Gary, IN were charged with stealing $100k using inflated mileage reports in their medical transportation business. Collins Anyanwu-Mueller of Westchester, NY was sentenced on Monday for stealing $392k from Medicaid using false claims for private-duty nursing care. He got caught when investigators found claims for the same time he was in Europe and for other times when the members were in a hospital or being cared for by another nurse. Frank Patino of Livonia, MI got nabbed for stealing 112M Medicaid bucks using an illegal opioid prescribing scheme. There is something in this story about Patino giving away free hams, but I can’t verify it. Please, please, please write in if you know anything about the hams. Patricia Lancaster of Wheeling, WV was convicted on false claims charges this week. She stole $181k from Medicaid by submitting false claims for “adult companion services” (seems like personal care services, based on what I am seeing). Problem is (in addition to the bogus claims) that she lived with the patient – which made her ineligible for the payments. She knew this, which is why she tried to hide it from the agency. Mr Patino – the $112M and intrigue of the hams put you over the top this week. You win! Taxpayer you lost (about $113M to be exact, just on the ones I found this week).

 

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 (batten the hatches! Summer storms are here) 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: Etseg delkhiig avrakhyn tuld Khüügee ilgeev

 

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Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2Ib98vV

For optimist readers- http://bit.ly/2Mdn62N

 WELL YOU SAID IF THE LEGISLATURE FUNDED IT… If you’ve been following LePage vs Expansioners, you know that the Good Guvn’r of Maine has sworn to not submit an expansion request to the federalis unless the legislature came up with the money to pay for it (seems logical, but I know desire/emotion trumps logic in our world…). On Wednesday a judge upheld LaPage’s right to not be forced to submit an expansion plan against his will. Then (also on Wednesday) the ME Senate and House approved $60M to expand the state’s program. Your move, Mr. Governor.

 NEW REPEAL / REPLACE EFFORT VIA APPROPRIATIONS? The House GOP budget teed-up on Tuesday includes $1.5T in cuts to Medicaid and “other healthcare programs.” There may also be hooks in the bill to allow for repealing ObamaCare without the Dem votes normally needed (I think this is the “reconciliation” maneuvering but not sure yet). GOP leaders are sounding the alarm over mounting debt and related fiscal crises if we don’t reduce spending. Where are my Medicaid #Resistance Fighters? Shouldn’t you be freaking out / yelling right now? By the way, the new legislation is called “A Brighter American Future.”

 

MEDICAID FRAUD UP 157% SINCE 2013 AND SENATE LEADERS SHOW CONCERN- A new report from the Senate Homeland Security and Governmental Affairs Committee shows Medicaid fraud skyrocketing since 2013 (and it was already ridiculously high). The report claims $36B is lost to Medicaid fraud each year. Some members are laying the blame at CMS’s feet for not “taking basic steps to fight Medicaid fraud.” It doesn’t help CMS’s case that GAO has been sounding the alarm for years. Of the 11 anti-fraud recommendations GAO has made in the last 3 years, guess how many CMS has implemented. Zero. I have been tracking and trying to bring emphasis on the disgrace that is Medicaid fraud for 15 years now.. Not getting my hopes up this report will change much.

 

DEMOCRATS OPPOSE FUNDING NEW OPIOID TREATMENTS VIA MEDICAID- The House passed a bill on Wednesday to cover new treatments for opioid addiction in Medicaid programs. The legislation will allow for funding for addiction treatment to go to facilities with more than 16 beds (this

gets at the IMD exclusion for those familiar with this part of the space). States have been asking – and receiving- waivers to allow exactly this funding. But proponents say the waiver process is taking too long and this law would speed up access to treatment. Opposing dems said it didn’t go far enough.

HOW MUCH DID YOU PAY IN STATE TAXES LAST YEAR? 17% OF THAT WAS FOR MEDICAID – Up from 13% in 2000, according to a new Pew study. All 50 states spent a higher percentage of their funds on Medicaid in 2016 compared to 2000. LA had the highest surge, going from 11% in 2000 to 24% in 2016 (they also expanded Medicaid in 2016).

 

PA AMBULANCES GET 33% MEDICAID PAY RAISE- Standard rates for Advanced Life Support went from $200/trip to $300 in the Keystone State. The Ambulance Lobby (usually its one dude in the state with most of the marketshare) is a real thing. I have seen it in multiple markets over the years.

 

MAJOR CHANGES FOR MDRP? MACPAC (the Medicaid and CHIP Payment and Access Commission) is recommending 2 changes: 1) stop letting pharma set Avg Manufacturer Price using brand and generics, and instead use the prices actually available to wholesalers. This matters because rebates set off of generic prices are lower (and using the generics in the calculation dilutes the amount states can get back). And #2) MACPAC wants HHS to be able to punish manufacturers that don’t provide good enough data to monitor compliance.

MOLINA GETS FLORIDA LOSS OVERTURNED- The MCO had lost its business in 2 regions as part of the recent procurement cycle. After a successful protest, Molina will now continue to serve members in 2 of the 11 FL regions. The new decision is important for Molina – at $550M / year in revenue, the 5-year contract now secures $55M in profits (assuming a 2% profit rate).

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 space this week. Get your fraud fix in the twitter feed (I put 20 or so fraud news items in there this week).

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 (pick tomatoes!) 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: Pityānē putrālā jagācyā tāraṇāsāṭhī pāṭhavilē

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Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2HND9BG (from the Arsenio Hall Show – How awesome is that?!?!)

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

 

NY BLEW $1.3B ON IMPROPER MEDICAID PAYMENTS- BUT WHO’S COUNTING?- NY State Comptroller DiNapoli (am I the only one who has long-thought “comptroller” is a very strange word?) released data this week showing $1.3B in “unnecessary” Medicaid spending since 2012. The audit pins the errors on electronic systems. State HHS officials say they are working on the issue and are trying to get the cash back. From what I can tell this could be a mix of inappropriate capitation to MCOs and TPL issues. If anyone in NY knows, please write in.

 

MR BEVIN GOES TO WASHINGTON (OR RATHER WASHINGTON LEFTIES GO TO COURT AND TRY TO DRAG MR BEVIN WITH THEM)- The lawsuit against KY’s work requirements (remember they call it “community engagement”; their opponents call it “work requirements”) is set to have its day in court this Friday. Keep in mind the long list of exemptions means no elderly or disabled person will have to meet the requirements (nor children or pregnant moms)- basically this new Medicaid innovation feature (its done under an 1115 demo waiver) will only affect a subset of the KY Medicaid expansion population. Stay tuned.

 

 NC SAYS NO TO STUDYING EXPANSION- A last minute amendment was added to a rural health bill on the floor this week, but it was promptly removed by the program evaluation committee. Committee leadership says it should be in charge of what gets evaluated, and that all efforts are focused on current efforts around bringing managed care to the state right now.

NASBO SAYS MEDICAID SPENDING TO SLOW DOWN IN NEXT FY, BUT THEN SPEED BACK UP- A NASBO report published this week shows most Medicaid program spending increasing by about 4.5% in FY 18’. When they take out their crystal balls for FY 2019, its around 1.5%. After this slow down, Medicaid hits the gas again and starts spending 5.5% more in future years. The report examines proposed Governor’s budgets each year. If the Medicaid spending adds proposed in those budgets goes through, and additional $5.3B in state funds will be added to the Medicaid industry next year. Well, a lot more than that when accounting for agencies overspending their budgets (which invariably will happen).

 NH SA PROVIDERS NEED MORE MONEY- They currently get $162.60 per patient per day for inpatient substance abuse treatment ($4,878/month). Providers say this is well below cost, and are asking for $10M per year from Medicaid.

 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.  Duke Ellington Ellis of Durham, NC will have to repay $1M (yeah, right!) for his role in fraud scheme in which he forged signatures of licensed psychologists to submit fraudulent claims. His company – gotta love the names they give these things – “Nature’s Reflections” stole $8.7M over the course of the scheme. LaGracia Burnett of Philadelphia plead guilty this week to stealing $211k for false claims for behavioral health services for autistic children. Seems she had broken the laws of physics and was delivering services at 3 different clinics at the same time. Arkady Goldin of Brooklyn stole $1.5M using a kickback scheme involving his pharmacy. He paid a local medical center employee to send expensive cancer scripts his way. Goldin also billed for drugs never delivered. And this is cool- the state figured that out by checking his Medicaid reimbursements against his orders from wholesalers. Mr. Ellis – you win this week’s award on sheer volume alone. Congratulations!

 

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 (build a nice fence) 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: ua tono mai te Metua i te Tamaiti ia faaora i te ao nei

 

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Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2KSCG2Y

For optimist readers- http://bit.ly/2KT2aNX (A Dick Cavett reference for my friend Jeff, the Tall Irishman)

 

 ABOUT LAST WEEK- There was way too much parenthetical thought (I apologize). [I will try to do better this week]. I promise.

 MINNESOTA ASKS FOR WAIVER TO ALLOW RESIDENTIAL SA TREATMENT- Now that views on residential treatment in places with more than 16 beds are changing (under the weight of the opioid epidemic), states are looking to relax rules meant to defund those horror-story mental health facilities from back in the day. If approved, MN will join 11 other states who have recently received the exemption to allow drug addiction treatment in facilities with more than 16 beds.

 NC ADDS WORK REQUIREMENTS TO MUCH-WATCHED WAIVER REQUEST- Journalists now see this as a poison pill to the NC effort based on 1 comment Verma made a few weeks ago about concerns over non-expansion states and work requirements.

GEM STATE REACHES VOTER CRITICAL MASS- The evolving nature of U.S. Government- in which the Constitution is but a piece of junk mail sent to us from those crusty, silly, old (add in still-socially acceptable slur here) guys back in the day from some place in the Northeast I think- now includes voters taking over the power of appropriations from Congress. Seems voters in Idaho are joining the mob of MoveOn-ers who think they can ballot anything they want into existence. Idaho activists confirmed they reached the necessary 58,000 signatures to put Medicaid expansion on the ballot in November. If they had to pay for what they are voting for, they would swipe their card for $3,206 (each, annually) to cover the costs (state and federal) for the 62,000 members their vote will add to the Medicaid rolls. But we all know its silly to expect voters to consider costs of their decisions. That’s someone else’s problem, right?

LEPAGE MAY GET OVERRULED- A Maine judge is deciding whether to order the state DHS to file a waiver request for expansion as chosen by voters. Roundup readers will remember that the Good Guvn’r LePage said he ain’t doing nothin’ to move it forward unless the legislature funds it.

SD WORK REQUIREMENTS PLAN GIVES SECOND CHANCES- SD policy makers have added another step before getting booted off if you don’t meet work requirements. Under the new proposal, bennies would get on a corrective action plan after not working 80 hours in a given month. Then if the CAP doesn’t fix it, they would get booted. The new feature is designed to avoid getting shot down by CMS as “too harsh” in a non-expansion state.

EVERGREEN STATE ANNOUNCES MCO WINNERS- The latest round of MCO awards in Washington concluded this week. Congrats to Amerigroup, Molina, UHC, CHPW and Coordinated Care. Special congrats to Molina and Amerigroup who nabbed statewide contracts for integrated care in all 9 regions.

VA LETS EVERYBODY DOWN-  Everybody hoping for expansion this week, anyway. Virginia Dems were expected to push through an expansion vote on Tuesday, but needed 1 Republican to defect to the SpendMore side. Without getting to much into the weeds of VA legislative procedure, basically this bill needs to get out of committee and it didn’t do that just yet. The majority leader in the VA senate announced this week that he expects it to pass, even if it does take a minute to work out the details. Be patient my dear Dems – you will be able to implode the VA state budget soon enough.

IOWA ON THE REBOUND WITH CENTENE – After a nasty breakup with Amerihealth, Iowa announced Centene is its new love interest this week. Announced this week, will start July 2019. Congratulations to all our Centene colleagues!

 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. Khurram Gondal of Ticonderoga, NY (and 11 other co-conspirators) were arrested this week for defrauding Medicaid out of at least $8M using their bogus transportation business. This scheme includes trips that never happened and kickbacks to complicit bennies. Roshanak Khadem (and 4 others) of Los Angeles were arrested on Tuesday for their part in a $20M scheme. Khadem (aided by a former Anthem investigator, who knew the ropes) and team would bill MCOs for things not provided using the billing numbers from bennies who were happy to get “discounts” on cosmetic procedures. Seems an allergy-related lab test CPT code was a hole about the size of a Mac truck in the MCO edits system. Keisha Demas of Brooklyn was arraigned this week for stealing about $500k, of which $60k was from NY Medicaid via a false claims scam related to her role as a nurse at Interfaith Medical Center.  Congrats, Roshanak- using a former MCO investigator as a fraud consultant gives you the style points needed to win this week!

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 (take some cutting, and propagate something already doing well on your property) 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: il-Missier bagħat lill-Iben biex isalva d-dinja.

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

For optimist readers- http://bit.ly/2y9t7L7

 

HEADED TO BALMORE. DO DROP BY AND SAY HELLO- I will be at MMCC 2018 starting Monday. Chairing a panel Tues morning. Would love for any and all readers at the event to say hi.

 

Y’ALL SIMMER DOWN NOW- NM recently awarded new MCO contracts. So the protests were filed by the losers. And HHS rejected the protests via the administrative process yesterday, so now the losers can take it to court. Yay! Even longer time to make changes needed for the program… Member impacts include uncertainty over whether they will have to switch providers Jan 2019. You have to understand the losers’ position though. It’s a lot of cash. Example – Molina had $1.3B in premium revenue in NM Medicaid last year. Assuming a 2% profit yields $26M a year lost if the protests don’t work out. So as long as the litigation costs less than $75M or so (3 years of premium profit in the market), why not roll the dice and sue? And that doesn’t even take into account impacts on market capitalization on news of losing key contracts, etc. Want to track the impact of lawsuit on stock price? Follow ticker symbol MOH on the NYSE.

  

SOUTH CAROLINA EXPANSION LOBBY PRIMES THE PUMP- The Urban Institute (are they still around?) just released a study showing the amazingly 1-sided impacts of a potential Medicaid expansion in SC. 194k would get “coverage” (please define “coverage” class, and then compare and contrast it to “access,” then triangulate it with “intersectionality” – oh bother, I lost myself) if the state moved forward with expansion. Per the study, the state would “only need to chip in $111M per year.” Because you know its magic federal money, that comes from the sky every time you wish upon a star. It makes no difference who you are. Anything your heart desires will come to you (and other states will pay for it!).

 

ALASKA SLOWING HOSPITAL PAYMENTS- Since the legislature did its job and passed a budget (you know, how the US Constitution and all state ones work?), there is $20M less than requested (do not make the mistake of confusing requested with “needed”) going to Medicaid between now and June 30. That’s about 45 days, people. So when you realize how people are freaking out (that they have to follow what the legislature says when it comes to appropriations) its clear Medicaid is living check to check. Normally the state cuts the checks weekly, but starting this week they will float larger providers a bit longer. Some reps point out that all this is driven by higher than projected costs of Medicaid expansion (remember when the Good Guvnr Bill Walker did it all by his lonesome back in 2015?), but those reps are quickly silenced and reminded on the non-politic nature of such comments. Even more daring reps point out that services for the most vulnerable are being impacted because of expansion overloads. Those reps are so offensive that they are immediately sent to Siberia. You can see it from the Governor’s back yard, you know.

 

PATIENTS SUE ILLINOIS OVER MEDICAID DELAYS- Illinois just can’t get it together. Seems like the state thinks after it sent us the best-President-ever they don’t have to do anything else at all. Resting on their laurels. Latest chapter in the dumpster-fire story (tragi-comedy? Especially considering sub-plot arcs over the years like Blagojevich) of the Prairie State is a lawsuit from patients suing over long-delayed eligibility applications. Seems the state is out of compliance with federal rules on determining temporary eligibility for new applicants. They are supposed to process apps within 45 days. The biggest pain points are in nursing homes. Per the write-ups I’ve seen, there has not been a single applicant approved under temporary eligibility since the summer of 2016.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph – not so fast. I was too wordy up top this week. Plus gotta keep you coming back for more.

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 (time to get the yard in shape for your Memorial Day party) 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: lēākaṁ rakṣikkānāṇ pitāv putrane ayaccat