Category: Clay’s Weekly Medicaid Roundup

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2y9t7L7

For optimist readers-  http://bit.ly/2y8BeaQ

 

A LITTLE LONGER THIS WEEK- Sit a spell. Let’s catch up.

 

STATES TO GET EASIER TIME ON WAIVER REVIEWS- CMS head Verma was at a conference this week in Ohio and let attendees know the agency is moving towards an
“unprecedented level of flexibility” for states to operate Medicaid the way they want to (v.s. being told what to do by the feds staring down the barrel of an FMAP). Sounds good to me, and should sound good to any freedom-loving person who thinks local autonomy is a good thing. Will of course ring alarm bells for lefties who want to continue using the feds to impose their views.

BADGER STATE STRUGGLES TO GET LEAD TESTS FOR KIDS- Guidelines require that kids get lead testing at 1 and 2 years of age. But it ain’t happening in Wisconsin. Less than 2/3^rds of Medicaid kids there receive them according to a new report. Especially concerning since Medicaid kids have a 3X risk of lead poisoning.

 

… BUT APPROVES MORE SUBSTANCE ABUSE TREATMENT— The Good Guvnr Walker announced pay raises for mental health and substance abuse professionals treating Medicaid members this week. All in all, the state will spend about $17M on the rate increases, with the hopes it will entice more providers to offer more treatment.

 

SUNSHINE STATE TIGHTENS TIME AND DISTANCE STANDARDS TO INCREASE PHARMACY NETWORK- Florida changed requirements on MCOs to now have to have a pharmacy within a 10-mile drive of all patients this week. The move added thousands of pharmacies to the overall managed care network, with Staywell adding 1,400 alone (Molina added nearly 900). There were not a lot of rx access complaints before the change, so some analysts are left scratching their heads. Based on what I am reading it may be related to an ongoing independent pharmacy v.s. PBM lobbying scuffle, but not sure. Please write in or call with any intel if you are there on the ground.

 

… ALSO MOVES FORWARD WITH PLANS FOR NEW DENTAL PROGRAM – FL is rolling out a stand-alone dental program March of 2019. The RFP (technically and Invitation to Negotiate, or ITN) was released last week. Bids are due April next year. Considering bidding? Give me a ring. This is one of the ones we are tracking.

 

 

EMBOLDENED DEMS GEAR UP FOR TROTTING OUT “PUBLIC OPTION” – After the multiple nothing-burger attempts at repeal died on the garbage piles of our Congress and Senate, “progressive” Dems (I love that adjective and how its used – what is the corollary- indeed is one allowed in modern discourse?- for Republicans whom journalists want to give them linguistic halos? I digress) are now trotting out the revolutionary (think Che) idea of selling Medicaid to the masses via the exchange. This is the “public option” that ACA footsoldiers dreamed of nearly 10 years ago. Senators from HI and NM are leading the charge. Let’s do a poll – would you buy Medicaid if you had a choice? Assume: no changes to benefits or network compared to Medicaid in your state today; you pay a similar percentage of the total costs as you do for your commercial coverage today; and there are no subsidies. Please do comment or write in on this one.

 

NM BUDGET GROANS, PARTLY DUE TO CHIP RE-AUTH UNCERTAINTY- $82M short for Medicaid this year. $31M is being pinned on CHIP, which is still currently in the air in The District. $15M is tied to the ACA expansion bill coming due (states like NM who expanded start paying more of the costs of that decision this year).

 

AZ GOP NOT GIVING UP ON FIGHTING EXPANSION, DESPITE D.C. GOP FAILURES TO REPEAL/REPLACE— If you’ve been following this, you know its been a long road. If you are pro-expansion, you view these guys as the zombies that just won’t die. If you are pro-taxpayer, you admire their stick-to-it-ness. After being denied at the state appeals court, the AZ lawmakers get their day in the AZ Supreme Court this week. Recap: Good Guvn’r Brewer expanded unilaterally. State GOP said it’s a tax passed without their consent, which is against AZ laws.

 

GOOD GUVN’R USES CHIP FUNDING CRISIS TO RENEW PUSH FOR EXPANSION- The state that brought us the Batman-Villain-Eyebrows VP Candidate, continues to grace us with current Good Governor McAuliffe (Virginia). The Good Guvn’r insists that the way to deal with CHIP uncertainty is to expand Medicaid. Can someone please let him that’s so 2015? The hip thing now, Terry, is to sell Medicaid on the exchanges, under the “public option.”

 

CONVERT YOUR NURSING HOME TO BE “COUNTY-OWNED” IN THE HOOSIER STATE, GET 30% HIGHER RATES FROM MEDICAID— All you have to do is lease your nursing home to a county health system and you get higher rates. Pretty much every facility in Indiana knows about the loophole now, so 90% of them lease themselves to county hospitals. No big deal though. Spending over past 5 years on IN nursing homes has only increased a paltry $1B. That’s less than 1% of a typical pay-off-Iran-in-the-middle-of-the-night-with-a-ship-load-of-cash scheme. Seems legit.

 

DIRECTORS SAY CAID SPENDING WILL INCREASE 5.2% IN FY 2018, V.S. 3.9% IN FY 2017— This is even with slower enrollment growth. Seems most states are resolved to pay most providers more (except hospitals). 

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. Isaiah Bongham, owner of Dynamic Visions (a home health agency in D.C.) has been ordered to pay back $2M he stole from Medicaid. Actually he stole $480k, but the Fraudulent Claims Act triples it (that’s cool). Santila Terry of Morgan Park, IL stole $1M using her speech therapy operation. She kept billing for services provided by an employee long after the employee left her firm. Christina Benson of Orlando was sentenced to 4.5 years for her role in a scheme that enticed homeless Medicaid members to get services at her psych rehab center. Mrs. Benson’s kickback scheme cost FL about $200k. Charline Brandon of Little Rock is accused of billing Medicaid nearly $300k for hospice care for patients without a terminal diagnosis. Jerrold Rosenberg of Jamestown, RI plead guilty this week to accepting $180k in kickback payments in exchange for prescribing a version of Fentanyl called Subsys. He was conspiring with AZ-based Insys Therapies. Cesar Tavera of Cherry Hill, PA was sentenced this week for embezzling $1.5M from the community mental health center he ran. His wife plead guilty to Medicaid fraud earlier this year.  Mr. Tavera – you win on sheer volume alone! Congratulations! This weeks total taxpayer tab: $3.5M.

 

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 (make a bonfire) 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: abeojineun sesang-eul guhagi wihae adeul-eul bonae syeossda.

 

Clay’s Weekly Medicaid RoundUp: Week of September 18^th, 2017

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2xjCC9z

 

For optimist readers-  http://bit.ly/2xkfN5j

 

OCEANIA INSPECTOR #1731- As service to my country (Oceania) I have enlisted as a social media inspector. My current duties are limited to tagging suspect articles with “thoughtcrime” but may expand pending further instruction from BB. If you see me comment on social media with this label please do not be alarmed. This entry was written with special digital ink only visible to good citizens who comply with the Party, so if you can read this you are OK. </doublespeak>.

 

FLIGHT OF THE NAVIGATORS- As ACA money dries up, Ohio is nixing its navigator program (navigators are sort of like guides to help applicants understand options for exchanges and Medicaid). We will likely see similar stories in other states over the coming weeks. In Ohio, the Navigators contract went to the OH Association of Foodbanks, which just watched its annual budget go from $1.7M to $485k.

 

ADD COLORADO TO LIST OF DEADBEAT MEDICAID STATES- Its taking a little while to work out the kinks of the new claims payment systems. Hospitals are owed a little north of $200M for services dating back to March (when the new system launched). There are currently 98,000 pending claims.

 

BRIGHT SPOT FOR NC BABIES AND MOMS- New results from North Carolina’s Pregnancy Medical Home are uplifting. The program is credited with reducing maternal mortality by 40% in the last 15 years. NC pairs a pregnancy care manager with high risk moms to help ensure the right dots are connected. There are about 400 of these pregnancy care managers across the state, helping about 25,000 moms each year.

 

FHN SELLING ENROLLMENT TO COOK COUNTY HEALTH SYSTEM- If you have been watching the Illinois market you know there are myriad challenges. All the stress and strain was too much for Family Health Network (one of the largest existing MCOs), and they are starting the exit process. Cook County Health System (a big winner in the recent contract awards) will start transitioning 160k legacy FHN members November 1.

 

COPAYS AND PREMIUMS MOVE FORWARD IN NEW MEXICO- State officials are moving forward with the plan to charge $10-$50 premiums for some members (with exemptions for the most poor and for Native Americans). Copays would be $2 for scripts, $5 for pcp visits and $50 for hospital admissions. NM is also considering eliminating retro-active coverage (for a discussion on how this work, and other states considering this same change – check out the recording of last week’s news show).

 

CHICKEN LITTLE FATIGUE- Another bill to dramatically alter Obamacare has been introduced, and the Resistance has been re-activated by Generals Slavitt, Schumer and Moore. In an amazing coincidence, the Graham-Schumer bill has the same purported outcomes as all previous 4 attempts this year – it will kill all babies, all the elderly and make the solar system implode. We haven’t done a deep dive on this one yet, but who needs it really? We know the truth from the media talking heads so why bother questioning what they say will happen if the bill would pass. (thoughtcrime)

 

PELICAN STATE RE-UPS MMIS WITH MOLINA- Molina got another extension (the 4^th 1-year extension), this time with a $46M price tag. MMIS-bid watchers collectively moved onto other states for another year…

I WILL BE AT MHPA 2017 IN OCT., WILL YOU? You can check it out here – http://bit.ly/2twCi5L Every 100th registrant will get a free Medicaid Foundations Course registration (our online training course).

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph… Not so fast my little fraud junkies. Not enough room in this week’s roundup, but I put plenty of fraud stories in the twitter feed for you. Check out the “food stamp millionaire” story for sure.

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 (even though the weather tricked us and its still not sweater 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: preahbeta ban chat preah botra aoy yeang mk sangkroh mnoussa lok

 

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

 

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

 

IT’S BEEN A LITTLE WHILE, PEEPS – Been running the conference marathon. Let’s do this…

 

IL COULD CUT RETRO-ELIGIBILITY- A proposal to CMS from IL HHS is asking to remove the need to pay for services up to 3 months before a member became eligible for Medicaid (for example if a health emergency hits and they can’t pay for it so they apply for retro-active eligibility). Estimates put this one at saving the state $37M. My question – does it matter if they’re not paying their bills for people who were eligible anyway? See also – IL has a multi-year, multi-Billion backlog to providers and MCOs.

 

AN ENTITLEMENT BY ANY OTHER NAME WOULD SMELL AS SWEET- The Good Guvnr LePage of the Pine Tree State (Maine) is ruffling the feathers of lefty-birds when he insists on calling Medicaid “welfare” in recent interviews. LePage continues to oppose expansion, much to the chagrin of our Progressive Overlords who know what’s best for state budgets (and of course are better, more moral people than those who care about other budget items). Here, Hear!

 

MS PROTESTS CONTINUE- The much-maligned managed care awards from the Magnolia state completed the administrative appeals process this week (with the agency affirming its decisions), but there remains a lawsuit to be dealt with. Amerigroup and True Health have raised red flags around lower scoring for some of their responses they think were very similar to winner’s responses.

  

ARMCHAIR MEDICAID PUNDITS IN D.C. SPECULATE TX MAY EXPAND CAID IN LIGHT OF HARVEY, CHANNELING RAHM’S “NEVER LET A GOOD CRISIS GO TO WASTE”- No one from TX has suggested such (yet anyway). From all the video I am seeing, Texans are pretty self-reliant. Maybe if CMS covers outboard motors under DME?

 

WELCOME BLAKE TO GA MEDICAID – GA DCH has a new director this week. Blake Fulenwider will start in his new role September 15^th.

 

BE ON THE LOOKOUT FOR THE MONDAY MORNING MEDICAID MUST READS NEXT MONDAY- Absolutely incredible article about interconnected players and companies inside CMS/HHS over past 2 decades.

 

THE VOX POPULI GIVES THUMBS UP TO MEDICAID WORK REQUIREMENTS- Politico polled about 2,000 people and 51% support tie-ing Medicaid to employment and 37% opposed. Food for thought as CMS weighs a pile of waiver apps to require weekly work hours to get a Medicaid card.

  

I WILL BE AT MHPA 2017 IN OCT., WILL YOU? You can check it out here – http://bit.ly/2twCi5L Every 100th registrant will get a free Medicaid Foundations Course registration (our online training course).

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. Mark Johnson of Janesville, WI pled guilty this week to stealing $740k from Medicaid using fake scripts. Antoine Skaff of Charleston, WV pled guilty this week to stealing $700k from Medicaid and MCOs for dental procedures not actually provided and for inflating billings for procedures that did actually happen. This one also includes the crowd dental favorite – getting paid for removing the same tooth multiple times. Hin Wong of Manhattan was popped for stealing $15M from NY Medicaid, using an HIV-drug kickback scheme. Ms. Wong spent the ill-gotten gains on plastic surgery, travel and luxury goods. Godwin Oriakhi of TX will spend 40 years in prison for his role in a $17M scheme that bilked both Care and Caid using a home health kickback arrangement (kickbacks were to patient recruiters and physicians). Victor Aldeza, Regino Aldeza, Albert Aldeza, George Aldeza and Lovelyemy Libao (all 5 are siblings) of AK stole $365k from Medicaid by pretending Regino was disabled. Chandra Wrightsell of Lincoln, NE was sent up the river for using her counseling company to file 1,200 false claims. Her tab? $100k. Ms. Wong – you win this week’s award! Total taxpayer tab this week – $33.9M lost to fraud. And remember – say it with me- that’s just the ones that made the news (99% do not). 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 (feel fall coming) 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: Äkesi Ulın qutqarw üşin Ulın jiberdi

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2wO7zhZ

For optimist readers-  http://bit.ly/2wOp6GQ

RED AND WHITE SMOKE SEEN ON DAY 62 FROM THE TOWERS OF THE MCO NEGOTIATION COUNCIL- After a few months of dancing around the issue of insufficient rates in the press, Iowa officials and MCO folks are in closed-door sessions to figure it out. New price negotiations were expected to conclude in July, but now its looking like mid to late August. In addition to price it looks like plans may be asking for more control over care management and utilization. You know, the things they are on the hook for. The number 1 complaint I hear from plan clients is they are held accountable for things they are not allowed the tools to impact. Hear, here.

 

PLANS BICKERING IN THE MAGNOLIA STATE- Amerigroup and Mississippi True are protesting the late-June MCO awards. United, Magnolia Health and Molina all won another round on the MS Medicaid ride. Mississippi True is a new provider-sponsored plan arguing that the RFP requirements around experience were designed to lock out any bidders besides the incumbents. Three state lawmakers are petitioning the Governor to instruct the Caid agency to take another look. Its nice to see lawmakers take such an interest in the Medicaid procurement process. I am sure they are Medicaid experts with a lot of insight into who the Medicaid agency should select and how they should evaluate proposals.

 

TARHEEL STATE SUBMITS REVISED MANAGED CARE PROPOSAL- This one is from the new Guv (Cooper), updating the one from 14 months ago by the old Guv (McCrory). Right now its shaping up to be focused on integrating physical and behavioral health (makes absolute since given the efforts in the NC market in recent years), telemedicine (a bit of a surprise), opioids and care management. No word yet on whether The Good Guvnr Cooper is looking to horsetrade with CMS to expand Caid enrollment. Let’s get managed care in there first, fellas.

 

IOWA DID NOT COLLECT $700K IN RX REBATES. SUBTRACTS AMOUNT FROM NEXT SFY BUDGET REQUEST- Just kidding on that last part. Silly kids! Medicaid spending NEVER, EVER goes down. If it did, the pink elephants at the center of the earth’s core would stop marching and our planet would fall from its orbit and go hurtling into space and we would all die because the Republicans hate everybody and only Democrats are GoodPeople. At least that’s what General Spend-It-All in charge of the Resistance tells me.

 

WONDERS NEVER CEASE. NEW CLAIMS PAYMENT SYSTEM IN THE CENTENNIAL STATE BEGINS LIFE ON STATUS: SNAFU- Colorado’s new claims payment system (interChange- note the lowercase first letter, but the Capital letter in the middle of the name. That means its sophisticated.) is not a hit with providers (at least the ones being interviewed). According to them, claims that previously sailed through are now being rejected. Many providers are out a good bit of cash and have decided to stop taking any new Medicaid patients until the problems are resolved. In defense of the new system all providers had to re-enroll during implementation, and many of the problems are being seen with ones who failed to do so. Other interesting parts of this story: The vendor is DXC Technology, which I guess is maybe a new MMIS-ish vendor? And the contract is for $187M over 8 years. That has to be the cheapest claims payment system I have ever heard of – even when the price does double like we all know it will. Hear that sound? That’s the sound of change orders piling up on some project manager’s excel spreadsheet somewhere.

LOOK UP DUMPSTER FIRE IN THE DICTIONARY AND YOU WILL FIND A PICTURE OF THE ILLINOIS STATE BUDGET- Its just terrible. Terrible. The stories won’t stop. This week: 10 IL SNFs were allowed to continue their lawsuit against the state for not getting paid the correct rate for 4 years. IL NPR also ran a story about various pediatricians out hundreds of thousands of dollars as they wait for the state to pay.

  

AND APPARENTLY JAMES COMEY IS IN CHARGE OF THE IL MEDICAID PRESS OFFICE?  I can honestly say I have never seen this: There was a news story this week letting the world know that CountyCare is a winner in the IL MCO bids. All the other winners (and losers) will have to wait until later to find out the rest of the results. Appears there’s a leaker in IL someplace.

  

I WILL BE AT MESC NEXT WEEK, WILL YOU? If so send me a note and let’s meet up.

I WILL BE AT MHPA 2017 IN OCT., WILL YOU? You can check it out here – http://bit.ly/2twCi5L Every 100th registrant will get a free Medicaid Foundations Course registration (our online training course).

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph … Not enough space this week. Lots of fraudster goodies for you in the twitter feed, though.

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 (practice your eclipse poses) 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: Viśvada uḷisalu tande maganige kaḷuhisalāgide

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

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

 

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

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

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

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

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

 

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

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

  

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

I WILL BE AT MESC IN 1 WEEK, WILL YOU? If so send me a note and let’s meet up.

I WILL BE AT MHPA 2017 IN OCT., WILL YOU? You can check it out here – http://bit.ly/2twCi5L Every 100th registrant will get a free Medicaid Foundations Course registration (our online training course).

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (tomatoes are finally red) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Sang Rama ngutus Sang Putra nylametaké jagat

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2vdvt9S

For optimist readers-  http://bit.ly/2v3Ugx6

 

CHECK FOR A PULSE-  Looks like Obamacare lives to skyrocket premiums another day (for those of us who still pay premiums, anyway). The Senate’s Skinny Repeal got shot down 51-49, with John McCain helping nix it along with two other Republicans. The night came with high drama, including a call from Trump to McCain (with Pence handing him the phone). McConnel is reported to have said “its time to move on.” My prediction: its done (at least for a long time).

 

BAY STATE BUSINESSES SUPER EXCITED TO PAY $300M IN FEES TO FUND INCREASING MEDICAID COSTS- Your reward as an employer in MA for providing jobs? Paying your employees’ healthcare costs AND $2k per employee to cover any Medicaid bennies on your payroll. Best. Plan. Ever. It’s a wonderful thing for politicians that 99% of Americans hated high school econ. The Good Guvn’r Baker’s plan is being scaled back, but not dead yet. If you want a vision of the future, imagine a boot stamping on a human face – forever. (Orwell)
TAKING IT UP A NOTCH- You know all those wacky states trying to add work requirements for non-disabled, non-elderly Medicaid bennies? Well if Senator John Kennedy of LA (cool name, rings a bell) has his way, Federal Medicaid regs will be changed to require it nationwide. Put this one on your watch list.

 

I WILL GLADLY PAY YOU ON TUESDAY FOR A HAMBURGER TODAY – IL finally started to pay some of the MCO tab last week – $750M in back payments went to plans. Now only about $3.5B more to go to get square. Reality is that which, when you stop believing in it, doesn’t go away. (Philip K. Dick)

 

ARKANSAS TRYING TO RESTORE COVERAGE FOR 2,000 IMMIGRANT CHILDREN EXLCUDED FROM MEDICAID BY BILL CLINTON- AR has about 12,000 Marshallese (The Marshall Islands) who got in under a 1986 law. Thing is Bill Clinton’s welfare reform (yeah, he did that) nixed any Medicaid coverage for them. AR DHS submitted a proposal to undo the Clinton coverage ban this week for the kids.

 

FLICKERTAIL STATE WILL COVER ABA FOR AUTISM- North Dakota Medicaid will cover applied behavioral analysis (ABA) for autistic children as of this week. Attempts by state reps to mandate commercial insurers in the state cover it were unsuccessful.

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. Tammie Sensenig of Denver, PA was sentenced this week to 4 years in prison. She already had a Medicaid fraud conviction, but lied about it and forged a background check when she got a new job as a behavioral health consultant for a company that provides Medicaid services. PA paid out $84k to the already-barred provider. Bharat Patel’s case this week in Norwalk, CT included video of him writing scripts in exchange for cash. He’s accused of stealing $4M from Medicaid by selling scripts to addicts. Meridian Senior Living Group in NC is being prosecuted for a $60M Medicaid fraud, based on comparing staffing levels to billable hours (hint -there’s not enough staff and too many billable hours). Meridian you win this week’s award by a mile! Total taxpayer tab this week: $64.8M. There was a lot more in Medicare but we stick to Caid here!

I WILL BE AT MESC IN A FEW WEEKS, WILL YOU? If so send me a note and let’s meet up.

I WILL BE AT MHPA 2017 IN OCT., WILL YOU? You can check it out here – http://bit.ly/2twCi5L Every 100th registrant will get a free Medicaid Foundations Course registration (our online training course).

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (It is nearly August and August is hot! Want to read Light in August with me? If 3 or more write in we’ll do a book club on it) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Chichi wa sekai o sukuu tame ni musuko o okurimashita

For optimist readers- http://bit.ly/2uxE8Re

 

Soundtrack for today’s RoundUp pessimist readers. On second thought, let’s do 2 optimist songs this week cause ‘Murica is awesome and its her birthday week- http://bit.ly/2uxG6Rs

 

DON’T FORGET MONDAY’S SHOW ALL ABOUT THE SENATE BILL- Alex Shekhdar of MHPA will take us all to school on what BCRA means for Medicaid funding. Sign up for free- http://bit.ly/2ccl593

SHAMELESS PLUG FOR OUR NEW ONLINE TRAINING COURSE: Check it out. We released it after years in the making. Here’s the video ad for it- http://bit.ly/2twQCeF

BADGER STATE HAS BUDGET SURPLUS- You’re not alone: I had to do a double take myself. Wisconsin will close out this SFY with Medicaid $325M to the good. Recipe for this fiscal success? Slower enrollment growth and more federal cash. Less spending and more “revenue” from Uncle Sam. Whooda thunkit?

 

LITTLE AMERICA ROLLS OUT 2 PROGRAMS TO FIGHT THE OPIOID SCOURGE- Maryland launched 2 new programs on July 1 aimed at getting ahead of the opioid epidemic. The first one deserves kudos because it targets how we got into this mess in the first place nationwide – Medicaid prescribing rules. The second one increases payments to residential substance abuse providers to help deal with the carnage. MCOs will be key partners, leveraging CDC opioid reduction guidelines.

 

LAND OF LINCOLN MUST PAY ITS BILL (SORT OF)- A federal judge ordered Illinois to pay its $3B Medicaid tab (the state has been stiffing providers and MCOs for quite a while). The court order has the state paying all new bills in full and on time, and establishes a payment plan of $293M in Medicaid back payments a month until its paid off. According to IL state Comptroller Mendoza, the new ruling “takes the state’s finances from horrific to catastrophic.” Don’t worry Mrs. Mendoza, I am sure the judge will point you towards the money trees so you can fix all this. (Hint – they are through that tiny little door in the back of Congress, in the small orchard in the back. The trees in the White House gardens have been out of order since November).

 

DENIZENS OF BLUEGRASS STATE MUST PAY THEIR OWN WAY (SORT OF)- The Good Guvn’r Bevin submitted a revised waiver request this week, looking to require bennies to work 20 hours a week if healthy enough to do so. This is up from the previous plan which had an increasing scale starting at 5 hours a week, walking up to 20 hours after a year of coverage. The new plan starts at 20 hours day 1 of coverage. Savings estimates mark the change at about $2.4B for KY by 2022.

 

SPELL WEARING OFF IN LAND OF ENCHANTMENT- Long-time readers may remember New Mexico cracking down on behavioral health providers accused of rampant overbilling of Medicaid (this was back around 2013, focusing on 15 facilities). Seems the state is walking back some of its claims (encouraged by a judge), and the attempted recoveries have plummeted from a total of $9.6M to $896k. Current finger pointing includes use of an extrapolated sample that did not have supporting documentation. One of the bigger issues is that Medicaid payments were stopped to these providers, causing disruption to members. Several of the organizations have been exonerated by the state AG. Good article on the details of this in the twitter feed (@mostlymedicaid).

 

NATURAL STATE ROLLING IT BACK- Arkansas submitted its request this week to modify its magical waiver (the one where they put expansion bennies on the exchange). Changes include knocking eligibility back down to 100% FPL (it was 138% to get the ACA cash), adding work requirements for those deemed healthy enough to work, and ending an employer-sponsored premium subsidy 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. TN is taking Med Management, Inc (MMI) to court for $7M in bogus claims for pain management. John H. Johnson of Hollidaysburg, PA faces 7 years in the slammer for his role in a patient-referral kickback scheme that stole $1.1M from Medicaid. Johnson sent Medicaid members to Universal Lab for tests in exchange for kickback payments. Dawn Bentley of Detroit was sentenced this week for her role in a $7.3M Care and Caid scheme. She providing billing services for bogus physician claims in exchange for a 6% cut. He biggest client- Waseem Alam- plead guilty last year to a $33M take. Anna Young of Chadron, NE must pay back $309k after admitting to billing $102k without sufficient documentation for her mental health services (she has to pay back 3 times what she stole). Mrs. Bentley – you win this week’s award! You are the first biller I have come across offering a fraud outsourcing service. Kudos!

 

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 (cook out again this weekend- celebrate the 4^th twice!) 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 Padre ha mandato il Figlio a salvare il mondo

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2u5LKtU

For optimist readers- http://bit.ly/2u2PRXL (a poppy bit for your vacation trip)

 

SHAMELESS PLUG FOR OUR NEW ONLINE TRAINING COURSE: Check it out. We released it after years in the making. Here’s the video ad for it- http://bit.ly/2twQCeF

I WILL BE AT MHPA 2017, WILL YOU? Chairing a Medicaid Director’s panel. Would love to see you there. You can check it out here – http://bit.ly/2twCi5L

DETAILS OF THE SENATE BILL THAT WILL KILL EVERYONE 4 TIMES OVER AND ALSO INCREASES CLIMATE CHANGE AND ALSO EVERY OTHER BAD THING WE CAN TACK ON TO THIS BILL THAT STOPS THE SPENDING ORGY WE HAVE ALL ENJOYED FOR DECADES, UNINTERRUPTED (BUT WE LOOKED NOBLE DOING IT, AND ALWAYS CLAIMED MORAL SUPERIORITY, SO WE’RE TOTES GOOD, RIGHT?) – Long headline, short link to good analysis on the timeline for the BCRA funding changes: http://bit.ly/2u1CDKM  Here is another one that compares the House and Senate bills in case you are into that sort of thing: http://bit.ly/2twMXxs

 

YEAH, BUT HOW DID WE GET HERE? As part of the frenzy to show what all problems Medicaid can solve, DJs have put the “Caid can solve the opioid crisis” EP back into the rotation. My suspicion is if you look at a chart oxycontin, et al volume over the last 20 years and slapped a category for payer on it that Medicaid funded the current opioid crisis. Am I crazy to think this? Write in and do tell.

 

IT’S THE BIG ONE, ELIZABETH! Please tell me you get the reference. Assuming you do, I am suddenly struck by the richness of what we all share via pop culture. Anyways… OR Caid has studies out now showing a 17% drop in cardiac arrests after expansion. Once patients got an insurance card in their pockets, they delayed care less and had that chest pain checked out.

 

MCOS IN ILLINOIS: MAY NEED TO WRITE THIS ONE OFF ON YOUR TAXES- IL State Attorney Stratton told a judge this week that the state simply does not have the cash to pay its Medicaid costs (as was asked by a recent Medicaid member lawsuit in response to the state not paying providers and MCOs). The lawsuit asked IL to pony up $500M more a month to get caught up. Stratton says the state may be able to come up with $150M a month for the pay-your-freaking-tab effort. Fortunately, healthcare superheroes from CA and NV flew in and paid for it out of their own pocket (they had a ton left over once their single-payer bills failed last week). Just kidding, we all know Bernie wrote the check.

 

SHOW ME STATE WANTS TO UN-SHOW EXPANSION- MO reps voted to freeze Medicaid enrollment in the expansion group to try and help deal with their budget crisis. All analysts expect this to trigger a fight with the Good Guvn’r Kasich.
CENTENE GOES ON PROBATION IN THE CORNHUSKER STATE- Seems the state is unhappy with the plan’s troubles getting behavioral health and home health providers paid.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Rabbi Zalmen Sorotzkin of Lakewood, NJ was popped this week for leading a $1M fraud bilking Medicaid and other benefit programs. Cheryl Mcgrath of Guysville, OH plead guilty this week to using her home health care company steal $2M from Medicaid via false claims, including for dead people or people in nursing homes at the time she claimed to be providing home health services. Anthony Handal and his fiancé Sandra Mora of Orlando, FL billed Medicaid for $160k of intensive family case management services they never provided. They would conduct an initial meeting with the Medicaid-enrolled families to get their member numbers, then never do anything else to help them (but billing FL Medicaid for 3 sessions a week for the family). Collins Anyanwu-Miller of Bridgeport, CT was arraigned this week for stealing $390k from Medicaid by falsifying home care claims. Mr. Anyanwu-Miller even managed to get paid for home care services that occurred while he vacationed in Europe. Mrs. Mcgrath- you win! (Taxpayers, you lose! Total tab this week: $3.6M).

 

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 (when the rain stops) 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: an tAthair chuir an Mac a shábháil ar fud an domhain

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2szI2LI (Pray for our nation. Even if you don’t believe in prayer. Or our nation. We gotta make as much noise as we can in the desperate hopes that He will hear us.)

For optimist readers- http://bit.ly/2szB7Sr

 

 

SHOUTOUT TO MY SOA PEEPS- Great time with my actuary friends at the SOA Health Meeting in FL this week. Thanks again to everyone for making it another great experience!

 

 

I’LL TAKE MINE WITH SPRINKLES- In case you haven’t heard, a rep from NV has thought of something none of us have in the 50+ years of the program: Medicaid for All! This is such a great idea, but why stop there? Why not Medicare for All (paging Dr. Sanders)? Or TriCare for All? Or BlueCross Blue Shield for All? If I would have known I can just append the magic words “For All” to something and get stuff without worrying about pesky things like costs, actual eligibility requirements and, oh, I don’t know, general freakin’ stability- I would have been namin’ and claimin’ it years ago (paging Dr. Osteen). Ferraris for All…Checklist of questions before you get starry-eyed on this one: What will be the FMAP (will there be FMAP)? Will provider rates stay at Medicaid rates? Will this be done with a State Plan Amendment, or an 1115 Waiver? Do you think CMS will approve either? Or, are you thinking NV is so serious about this, it will do it all with state-only dollars? What percent of individuals (now that the individual mandate is likely gone) do you think will choose to “buy” Medicaid on the exchange (would you buy Medicaid if you had a choice)? How will the subsidies for this one work? Will anyone buy it without a subsidy? If the state is selling coverage (Mike Sprinkle’s plan) and calling it Medicaid, is that actually Medicaid? Is the state now an MCO and subject to MLR rules, MCO taxes, etc? Hashtag: ImportantQuestions.

 

GOING, GOING, GONE! Any hopes that expansion costs would ever flatten out, that is. New data shows state expansion costs in 2018 will be $8.5B- more than a 100% increase over 2016. Some of this is that the tab is finally come due (states started paying a % of costs this year), but a lot of it is states’s eyes were bigger than their stomachs and expansion costs a LOT more than dreamers ever dreamed.

 

MEDICAID IN THE GOLDEN STATE FOR EVERYBODY? NOT SO FAST- CA reps dropped plans to give Medicaid to all undocumented persons in the state. There were plans to use tobacco taxes to cover the initiative, but seems those $s will instead go to increase Medicaid provider rates.

 

SOONER STATE WILL PAY DOCS LATER RATHER THAN SOONER- OK Caid officials have proposed to float payments to providers by a month in order to not decrease rates. Not sure I understand the overall logic, so write in if you know more. Scarily similar to what we wrote about last time re: IL being $2B behind in Caid payments.

 

BEAVER STATE GETS NEW TAXES TO FUND CAID HOLE- OR reps passed a new $550M tax on hospitals and health plans to avoid Medicaid cuts. The state faces a $1.4B budget hole (not just Caid).

 

HEALTH HOME PROVIDERS BEG FOR MORE BREAD IN THE BEEHIVE STATE- Home health aides now have better employment options with the upturning economy, and Utah home health agencies are asking for more Medicaid funding to be able to pay employees more than their other options.

 

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Alan Nisselson of the Bronx plead guilty this week for his role in a $27M false claims Medicaid fraud conducted by his company Narco Freedom. Elizabeth Powell of Helena, MT plead guilty for her role in a $450k Medicaid fraud involving physical therapy claims. She got her family to say they were getting PT and then diverted the payments out of the physical therapist’s bank account. Kester Atumonyogo of New York was indicted for stealing $1M with a nutritional formula fraud. Mr. A used a stolen SSN to enroll his DME company (Monack Medical Supply) and then started billing MCOs like mad. Robert and Kristina Corrado (father and daughter) of Nesconset, NY stole $2M from Caid using a kickback scheme that provided housing to homeless people only if they agreed to get treatment at their substance abuse treatment center. Wilbert Veasey, Jr. of Dallas, TX was sentenced to 17 years for his role in a $400M home health fraud ($500k was Caid, $22M was MediCare). Kathleen Tuorila of Del Rio, TX was sentenced this week for her role in a $3.5M DME Medicaid fraud. She helped submit false claims for power wheelchairs. Total taxpayer tab this week: roughly $57M. Congratulations, Alan- You win!

 

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (Weeds everywhere!) 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: Bapa mengutus Anak untuk menyelamatkan dunia

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2rMf8Yi

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

 

I SEE CHICKEN LITTLES (READ THAT IN HALEY JOEL OSMENT’S VOICE FROM THE 6^TH SENSE)- For all those screaming that the Medicaid world is ending, please see my article last week “A Few Charts re AHCA and Medicaid” (http://bit.ly/2rM9Pbl). We were flying the plane 90 degrees straight up (into the white hot burning sun); now its tacking at about 87 degrees. If you are going to freak out about the “cuts” at least be honest and use the real numbers. Any corrections to my #s / charts much appreciated. Send me a note and I can send you the spreadsheet and we can revise together. It would be like a group project in highschool.

 

SEEMA SAYS- An interview with CMS chief Seema Verma came out this week in USA Today, which is pretty cool because the recently former acting CMS Admin Andy Slavitt (now turned townhall superhero/the Michael Moore of Healthcare) is sort of on staff at USA Today as well. So, balance I guess. Anyway, Seema says that whole state-fed partnership thing is really out of whack in favor of top-down D.C. bullying, and its time for the states to have some actual say in the program, even if it means occasionally going against the D.C. money dealers. Somebody pinch me.

 

SAGEBRUSH STATE SEEKS TO EXPAND- Mike Quixote, er I mean Sprinkle, submitted a bill to expand Medicaid in Nevada this week. Good luck, Mike. Let us know how it turns out!

 

AMERICA’S DAIRYLAND ASKS YOU TO PEE IN A CUP- Wisconsin legislators approved the Good Guvn’r Walker’s drug testing provision for Medicaid coverage this week. Now it just needs to get covfefe-ed by President Trump’s CMS Administration.

 

PRAIRIE STATE SLOWING DOWN MCO STRATEGY- Dems in Illinois passed SB 1446 to require the state to use the normal procurement process in its attempts to expand managed care. Seems current state DHS officials have been using a different process (but not a new one), and legislators think it should be more transparent.

 

THE MUSIC HAS STOPPED AND MEDSTAR DOES NOT HAVE A CHAIR- D.C. MCO awards are out, and MedStar (an incumbent with about 60k bennies) is on the losing list. Per the D.C. report, MedStar had 40% higher costs and a higher service denial rate. MedStar responded that their bennies needed more pharma, but it wasn’t enough to sway the judges. Winners include Trusted Health Plan, AmeriHealth Caritas, and Anthem. Congrats to all our colleagues in the winning MCOs.

 

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.  Ronette Brown of Bristol, CT was convicted this week for $200k worth of bogus psych therapy. Barbara Wallace of Savannah, GA was sentenced to 41 months for stealing $948k from Medicaid. Her crime? Selling unnecessary medical shoes. Complementary Support Services of Minnesota settled its Medicaid fraud suit for $4.5M. CSS was a mental health provider that fabricated patient records to get paid. Sonia Ponce of Freeport, NY stole $75k by inflating home healthcare aide time sheets under the state’s Consumer Directed Health Program. Total taxpayer tab for this paragraph: $5.8M. CSS you 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 (Everything is sprouting!) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Nna zitere Ọkpara ịzọpụta ụwa