Category: Clay’s Weekly Medicaid Roundup

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

Or you can click the one for optimist readers –  http://bit.ly/2gUFq0R

 

MAKE MEDICAID GREAT AGAIN- I have had clients and readers ask my thoughts on what President-elect Donald Trump’s shocking (gasp!) victory means for Medicaid. I have intentionally waited a few weeks for the dust to begin to settle.  You can read my thoughts here- http://www.mostlymedicaid.com/?p=1874

Since most of the Medicaid news in the past few weeks has been speculation over what the Trumpening means for Medicaid, I have reserved this week’s RoundUp for news summaries of other items.

BUT FIRST, A CORRECTION – An earlier RoundUp incorrectly listed the Good Guvn’r Brandstad as the Governor of Illinois. I have written it correctly at least a dozen times (he gives me lots of material), but the one time I get it wrong, I hear from Richard, Rob, Marni, Claudia and others who wrote in to Correct the Record. I love it when people write in, and I love it even more when they provide corrections. It means they are paying attention. Thank you, and everyone – keep me honest!

 

SPEAKING OF IOWA- MCOs playing in the Iowa statewide rollout continue to post loss numbers (in the press). Losses in the latest stories range from 18-25% for UHC, AmeriHealth Caritas and Amerigroup in the Hawkeye State. The Good Guvn’r Brandstad tossed another $33M in the MCO pot in October to help cover unexpected costs (especially Rx). Its not all dollars and sense, though- 25,000 members now are getting care coordination services, 230,000 have been engaged with health risk assessments and other outreach efforts and more than 2,000 have been taken off the waiting list for a DD program. Aren’t these smashing successes? Where are the advocates showering confetti and throwing a parade for the MCOs? Seems a bit one-sided to me. Sometimes the naysayers remind me of cavemen- “MCO bad. Me get angry. Me repeat tired arguments against MCOs and me ignore abysmal outcomes in fee for service.”

 

ARKANSAS STRUGGLING TO KEEP UP- About 28,000 Medicaid applications are in purgatory in the Natural State. DHS officials are still saying they can get them all done by year end (that’s now less than 3 weeks when you adjust for the impact of the Christmas break).

 

MEDICA MCO WALKS AWAY FROM MINNESOTA- About 300,000 bennies in the Gopher State will need to cut up their old Medica card (“Medica” is the MCO name, which is confusing, and looks like I dropped an “id” or an “re”). Medica says it will end up losing around $150M on 2016 Minnesota Medicaid business. Of course the party line is: ”The evil MCO is making too much money and got greedy.” Assuming they are not lying, can you blame any business for wanting to not lose money?

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. Deborah Brown of Warwick, RI will serve four years and pay $230k for billing for DME (incontinence supplies) not medically necessary. Gregory Dodds, a counselor in Camdem, AR was ordered to pay $250k for defrauding Medicaid. His counseling practice operated from inside the building for Camden’s “Connection International Ministries Church.” His excuse? Mr. Dodds needed to pay off student loans. Bernie – where are you? Riyad Altalla and his wife Muna Alnoubani pled guilty to using their home health company to steal more than $1M from Ohio Medicaid. The lovely couple from Ohio wins this week’s award.

 

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 fire! And while you are at it, read London’s “To Build a Fire”) 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: mamam moavlina dze gadarch’ena msop’lioshi

Today is Veteran’s Day. In honor of those who have served in our nation’s military, please take a moment to read about the brave men and women who protect us. I have taken stories of fallen servicemen and servicewomen from the site thefallen.militarytimes.com. This selection is in no way meant to slight veterans who did not fall in the line of duty, or who fell earlier this year (the LinkedIn character limits do not allow more than a few to be shown). Please pray for the widows, children, parents and friends of those so recently fallen.

 

Staff Sargent Matthew C. Lewellen. Killed November 4, 2016 in Jordan (7 days ago). Green Beret, 5^th Special Forces Group. Hometown: Kirksville, MO. Age 27.

 

Staff Sargent Kevin J. McEnroe. Killed November 4, 2016 in Jordan (7 days ago). Green Beret, 5^th Special Forces Group. Hometown: Tuscon, AZ. Age 30.

 

Staff Sargent James F. Moriarty. Killed November 4, 2016 in Jordan (7 days ago). Green Beret, 5^th Special Forces Group. Hometown: Kerrville, TX. Age 27.

 

Captain Andrew D. Byers. Killed November 3, 2016 in Afghanistan (8 days ago). Company B, 2^nd Battalion, 10^th Special Forces Group (Airborne). Hometown: Rolesville, NC. Age 30.

 

Sargent First Class Ryan A. Gloyer. Killed November 3, 2016 in Afghanistan (8 days ago). Company B, 2^nd Battalion, 10^th Special Forces Group (Airborne). Hometown: Greensville, PA. Age 34.

 

Staff Sargent Adam Thomas. Killed October 4, 2016 in Afghanistan (38 days ago). Company B, 2^nd Battalion, 10^th Special Forces Group. Hometown: Takoma Park, Maryland. Age 31.

 

Aviation Boatswainís Mate (Fuels) Airman Devon M. Faulkner. Died September 20, 2016 (52 days ago). Assigned to USS Wasp, forward deployed in the central Mediterranean Sea. Home: North Carolina. Age 24.

 

First Lieutenant Jeffrey D. Cooper. Died September 10, 2016 in Kuwait (62 days ago). Headquarters Company, 2^nd Battalion, 502^nd Infantry Regiment, 2^nd Brigade Combat Team. Hometown: Mill Creek, Washington. Age 25.

 

Staff Sargent Matthew V. Thompson. Killed August 23, 2016 in Afghanistan (80 days ago). 3^rd Battalion, 1^st Special Forces Group (Airborne). Hometown: Irvine, CA. Age 28.

 

Staff Sargent Christopher A. Wilbur. Died August 12, 2016 in Afghanistan (91 days ago). 1^st Battalion, 12^th Infantry Regiment, 2^nd Brigade Combat Team, 4^th Infantry Division. Hometown: Granite City, IL. Age 36.

 

Lieutenant Colonel Flando E. Jackson. Died August 4, 2016 (99 days ago). 194^th Wing, Camp Murray, Washington National Guard. Hometown: Lansing, MI. Age 45.

 

First Lieutenant Anais A. Tobar. Died July 18, 2016 in Southwest Asia (116 days ago). 4^th Aircraft Maintenance Squadron, Seymour Johnson Airforce Base. Hometown: Miami, FL. Age 25.

 

To any veterans reading the roundup today, thank you for your decision to protect me, my family and my way of life. Thank you!

To any of the fallen, you will certainly have much more joy at the feet of Jesus than reading my silly little RoundUp. Thank you.

To Paw Paw (Sargent Major Ott Cecil Farris, Marine veteran of WWII, Korea and Vietnam)- I miss you. We all do. We are all so grateful for what you did for us so many years ago. And we all look forward to seeing you again.

To Private William Robert Caddy of Quincy, MA, thank you for jumping on that grenade on Iwo Jima on March 3, 1945. You saved my grandfather’s life (and the life of another Marine pinned down under Japanese sniper fire). It was thus possible for my father to be born 4 years after that, me to be born 28 years after that and my first child to be born 31 years after that. Your sacrifice upon that grenade has had impact for 61 years and counting. You are in no way forgotten and never will be. I will tell my children of you and they theirs.

Thank a veteran today. Thank one tomorrow. Pray for one today. Pray for one tomorrow. Buy one lunch. Pull your head up from the cesspool of the 24 hour news cycle and do something to honor them.

And each and every day- Praise God you were born in a country worth dying for.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2eH0oQa

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

 

Millions in Academic funding Goes Away- I must admit even I haven’t seen this happen in Medicaid. VT has taken $4M from academic medical centers and given it to family doctors. The redistribution was required in a bill passed last session, and appears to be aimed at maintaining the higher primary care payment rates ACA made possible for 2 years back in 2012-2014.

(Illinois) Medicaid Again Gets Allocation increase- Whatever you think of The Good Guvnr’ Brandstad’s managed care strategy, you have to give him props for stick-to-it-ness. When the press just won’t stop criticizing your decision to move to managed care, and attack you for 2 years with every story they can? Add $33M more to the MCO budget this year and tell those journalists to shove it. Brandstad claims the additional spending is possible because managed care has been even more efficient than predicted, and he is still on track to deliver the $110M in annual savings he promised.

(Virginia) Medicaid Annual costs Go up Again- New numbers out from a VA budget groups shows FY 2017 going up $281M. That’s a 7% increase in Medicaid spending over last year. This upward adjustment comes roughly one year after the most recent update to the VA spending forecast, which also showed staggering increases (and a $1.5B budget gap). Can anyone guess what the go-to solution being touted by The Good Guvn’r McAuliffe is?

Managing Affordable (care act’s perception) Goes Awry- It’s just gotten so very hard to pretend like ACA is successful at doing anything besides reducing the uninsured rate. And somehow, John Q. Public has caught on that even that is not so impressive for a policy that forces people to get insurance via penalties. For easy reference, I have placed a few links to the most relevant stories to come out in the last week or so here, here, and here. To me, the funny thing is that ACA really just decreased access for all the people that already had insurance (via higher deductibles that have a clear cooling effect on seeking care). Looks like all the king’s horses (pundits) and all the king’s men (whackjob healthcare economists) couldn’t put poor ACA back together again. I would write more in depth analyses, but it is considered impolite/impolitik/crimethink in our little healthcare world to do so.

 Managed (care) Assessment Gets Adjusted- States that rely heavily on taxing MCOs to deal with budget boo-boos are struggling under the new federal rules that require they broaden (tax more types of managed care entities besides MCOs) or eliminate the revenue stream – good LORD I lost the verb in here somewhere. Wait, nevermind- its just a few words after “boo-boos.” Anyway, they are struggling. Ohio is a good example, with one county standing to lose $20M in annual funding. Kasich is promising a fix but not a lot of details yet. Some predict he could mimic what PA’s Good Guvn’r Wolf did last year, implementing a $13 pmpm “assessment” on all MCOs. So basically, use a different word for tax to keep the money flowing.

LOTS OF OTHER THINGS THAT JUST WOULDN’T FIT – I missed deadline for last week’s RoundUp, so the twitter feed is especially full this week. News from this week and last on there, including lots of fraud stories.

 

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 (go vote on Tuesday! The founding fathers bravely rejected the oppressive, corrupt rule of the elites of their day, and you can too) 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: Pai enviou seu Fillo para salvar o mundo

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2dUj8v7 ( bonus song- http://bit.ly/2dUhABf )

 

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

 

RUH-RO IN OR: Looks like OR Medicaid may be un-invited to all the nice parties again (for those of you that remember the scandalous Medicaid-coverage-leads-to-worse-outcomes stories a few years back). New, long term studies have confirmed that the 40% ER spikes seen after expansion are sustained. The “pent-up demand” theories that assured us it would go down after initial uptake were proven false.

SHOW ME STATE SHOWED US THIS WEEK: Who the new MCO winners are, anyway. Centene, WellCare and UHC – Congratulations! The new contracts include a significant expansion (adding 61 counties). Aetna lost out on this one – and lost 270,000 monthly cap payments as well.

HUGE PROPS TO AMERIHEALTH CARITAS OF PA- The MCO achieved what only 14 others did nationwide – a 2016-2017 NCQA rating of 4.5. Keep up the good work!

VIRGINIA IF FOR (DEFICIT) LOVERS- VA has a $1.5B deficit, resulting in layoffs, agency cuts and other measures. Despite all this (but of course he argues because of all this), the Good Guvn’r McAuliffe is nagging/lobbying for VA to expand Medicaid again. Trot out the “but it’s free money from the federal government – they get it from the money trees in DC!” argument. Thinking people know that its not free, and it does add hundreds of millions more in the state share of Medicaid costs.

GET THOSE WAIVER APPS IN QUICK, PEOPLE- Seems like CMS is thinking there might be some sort of change that impacts federal healthcare policy happen in November? Any idea what that could be? For waiver apps that are in line with CMS desires, there is a fast track lane. Case in point- WA just got preliminary (helps us have something to latch onto post-November) approval of a new $1.5B Medicaid reform waiver. The WA deal will include monies to revamp LTC (among other things, most of them focused on shifting to value based care and out of FFS). Now if you’re KY and wanting to dial back expansion, well you’re request somehow made it to the bottom of the pile.

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. “Dr” Stanley Marable plead guilty to Medicaid dental fraud in Valdosta, GA this week. He stole $789k from GA Medicaid for tooth extractions that didn’t happen. OmniCare, the largest institutional pharmacy in the U-S of A (it’s a nationwide nursing home pharmacy) has agreed to pay back $28M to various state Medicaid programs over allegations it conspired with Abbot labs in a kickback scheme to increase Depakote sales. Robert Novy, and elder-law attorney of Brick, NJ was charged this week for defrauding clients out of $1.2M. He presented himself as an elder advocate, “helping” clients navigate Medicaid financing issues (think estate recovery), but in reality he was (allegedly) taking control of their finances and stealing their savings. OmniCare- you win this week’s award. I would make some witty quip about seeing you in orange and in jail, but it seems like more and more powerful people / corporations are above the law these days.

 

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 a rain dance for AL- we need it!) 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: Isä lähetti Pojan pelastaa maailman

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

 

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

 

THE TIMES THEY ARE A’CHANGIN’- CMS and OIG released a joint proposed rule (is that normal?) to update the state MFCU (funny sounding acronym re: state fraud units for those unaware- and yes we all think it sounds dirty when you pronounce it like a word) regs that are basically unchanged since 1978. The changes will align the reg with statute changes as well as with best practices. There’s a good many updates- I recommend one of the summaries from JDSupra and others (check the twitter feed).

 

CONGRATS TO NE FOR APPROVAL FOR HERITAGE HEALTH- NE has gotten approval from CMS to launch its innovative integrated care approach to managed care. The state already has 80% of bennies in managed care – the new program will now have MCOs running admin for physical health, mental health, and Rx. Heritage Health is set to launch Jan 1.

 

KS STRUGGLING. STILL STRUGGLING- RoundUp readers and show watchers know we have been talking about the KS backlog since the summer. This week saw a new lawsuit (with a nursing home suing the state on behalf of 21 patients that could get kicked out if their apps don’t get approved and I mean fast) and new concerns expressed by legislators over a new lurking backlog. Seems the initial backlog (which is almost cleared) was actually under-reported by about 12,000 applications. From what I can tell, the 12,000 now in the cue are mostly renewal applications.

 

TN SAVING BOUCOUP BUCKS WITH EPISODE-BASED PAYMENTS- TN Medicaid moved to episode based payments in 2013 and is now able to report it saved $11M in year 1 with the value vs volume approach. Nice to see its paying off! Congrats to Brooks Daverman and team (check out the April episode of the state spotlight on the website to get a deep dive on the TN model).

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. Philip Esformes of Miami is charged with running a 14-year, $1B Medicaid fraud scheme. Seems he and his father used bribes and kickbacks to increase payouts to their network of nursing homes.  Katia Donnelly, a DME company owner in Huntington, NY plead guilty this week to stealing more than $2M from Medicaid. Francis Kimaru and 2 others running Compassionate Homecare (Worcester,MA) were indicted this week on $800,000 worth of Medicaid fraud charges related to unnecessary services and services not authorized by a physician. Chanda Hall of Baker, LA was sentenced this week for using her home care company (Empowering Care Services, LLC) to steal $1M from LA Medicaid. How did Chanda get caught? When paramedics were sent to the home of a patient who had been supposedly receiving services from Empowering Care, but had been in fact abandoned a while back. Paramedics reported the patient was “severely malnourished and neglected to the point where (her) own fingernails had grown until they were curving around and growing back into the flesh of her palm.” Once patient zero was discovered, the larger fraud was identified. Medicaid fraud has very real consequences for vulnerable patients, people. You can take your “oh, but its just a drop in the bucket” and shove it. Chanda, you’re not the biggest this week, but in the spirit of the upcoming Halloween/Election season, you win on evil factor alone. I pray your jailors take better care of you than you did those entrusted into your care.

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 some sort of hay/pumpkin decoration- you know you want to) 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*sinugo ng Ama ang Anak upang iligtas ang sanlibutan*

Soundtrack for today’s RoundUp pessimist readers-  http://bit.ly/2d0HUcn

 

Or you can click the one for optimist readers – http://bit.ly/2d0J3AE (in which Ginger Rogers sings a verse in pig latin in 1933)

 

THE LAST FRONTIER AND ACS (ER, XEROX) SETTLE THEIR DIFFERENCES- The original complaints centered around Xerox not getting provider payments out the door fast enough (and some payment errors, too), and the state wanted $47M in damages. The settlement announced this week landed on no hard cash penalty, but instead AK will get 100,000 hours of “free” work in the deal. Shareholders do not fear – looks like the state will still pay the full contract amount for the DDI and Ops. Subscription revenues continue- Phew!

 

WE NOW HAVE A LABEL, AND ITS “CONSERVATIVE” MEDICAID EXPANSION- Looks like cost-sharing (via HSAs and optional coverage buy-ups) for health insurance bennies is now called “conservative” based on this week’s Modern Healthcare analysis of the Anthem analysis of the Healthy Indiana Plan (HIP). For those unfamiliar, Anthem has about 150,000 bennies there. So they have a bit of perspective on what’s going on. According to the Anthem analysis, 70% of all Medicaid bennies chose to buy up into the “HIP Plus” option (which gets you dental and vision on top of what you get for HIP Basic). Nearly 60% of bennies with less than $230/ month income chose to buy up into Plus. And it looks like having a Plus card in your pocket has positive impacts – preventive screenings (which are covered under Basic, too) go up and ER goes down. The essential read is that when given choices for more coverage and a small cost, people choose it and it changes their behaviors. Shorthand – skin in the game.  Some establishment advocates are pooh-poohing it, saying its hurting Basic (remember the coverage is the same for everything except vision and dental), pointing fingers at MCOs to say “what are the MCOs doing to get them to more screenings and preventive visits?” No one is asking what the members are doing, of course. Back to that label in the headline. Some say “conservative” Medicaid expansion. I say “responsible” Medicaid expansion. Cue outrage, name-calling and snake-oil health economic theories that ignore basic human behavior.

 

DO-DO-DA-DO-DO [TRYING TO GET THE “WE’RE IN THE MONEY” MELODY ACROSS IN A HEADLINE]- MCOs added 3M bennies this year. Assuming an average cap across all rate cells of $200, that’s $600M more in revenue. Further assuming 2% profit, that’s another $12M added to the bottom line. Still small potatoes compared to 2015’s MCO enrollment surge of 8M, though.

 

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. Steven Schwartz of Chicago was charged with billing for $60k in personal assistance services not provided. Glenn Schabel of Long Island was sentenced this week for his role in nabbing $150M for prescription meds he then diverted to the black market (he was ordered to pay back $5.5M). First Call, a medical transport company in Buffalo, NY, agreed to pay $173k to settle allegations it got Medicaid payments for rides made by unqualified drivers. Physician’s Ambulance Services (in Cleveland, OH) basically got popped for the same thing, to the tune of $109k. Mr Schabel– you have impressed us all with the size of your pilfery. Go forth – through those iron gates over there to your left. See you in a few years.

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 a break from the 24 hour news cycle – isn’t it terrible?) 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*Isa on läkitanud Poja maailma päästma*

Soundtrack for today’s RoundUp pessimist readers-  http://bit.ly/2d5jGkN

 

Or you can click the one for optimist readers – http://bit.ly/2d5kvKm

 

 EVERYTHING’S BIG IN TX, ESPECIALLY THE MCD BUDGET DEFICITS- Medicaid is looking at a $1.3B “shortfall” (translation – the evil legislature has told them they have $1.3B less to spend than they did last year) in the Lone Star State.

 

“NO DICE,” SAYS THE BIG HOUSE TO BUCKEYE STATE- When costs and enrollment was double what the Good Guvn’r Kasich (anybody seen that guy lately?) promised, Buckeyes left with the tab decided to try and make a few changes: require contributions to HSAs, patient cost-sharing (2% of annual income or $99, whichever is less), a healthy behavior program (like nearly everyone employed by a larger corporation has) and a workforce training program. Where on earth did those evil Buckeyes come up with such hateful ideas? CMS roundly rejected the idea (saying hundreds of thousands – no millions!- would lose coverage), laughed heartily at the request, patted OH on the back and murmured something about how cute it was they thought states had control over their Medicaid programs.

 

“BUT YOU’RE COOL,” SAYS THE BIG HOUSE TO THE WOLVERINE STATE- Early reports out of MI – where expansion enrollees above 100% FPL have been required to pay premiums and contribute up to 2% of their income into HSAs (where have I heard that before) – suggest that its going great! The majority of the new bennies say they are now healthier. 99% of them agree their coverage is affordable. To be fair, the MI way does not stop coverage if you don’t pay your premiums – but it does allow your tax refunds or lottery winnings to be garnished.

 

“P.S., YOU’RE PROBABLY SCREWED, TOO, BLUEGRASS STATE,” SAYS BIG HOUSE RIGHT BEFORE MIC DROP- Well, the bipartisan (  🙂  ) Kaiser Health News said it this week, so basically same difference. CMS will say it next week. You guessed it – KY is asking to make similar changes as OH asked for.

 

THAT ONE CHART, THOUGH- The bruising ACA took a few weeks ago with all that silliness about exchanges imploding and costs being way higher (who the heck cares about cost in Medicaid, anyway?) has just about ended. Forbes did manage to squeeze out one more salvo this week (check the twitter feed). Of special interest is the set of charts showing the 4 (count em’, 4!) CBO estimates (1 original, 3 revised) of ACA costs and enrollment. Try not to pull a Jon Stewart (make sure you put down your coffee before you read it).

 

BADGER STATE ONLY ASKS FOR HALF-BILLION MORE THIS YEAR; CALLS IT A SUCCESS- Last few years’ requested increases have ranged from $650M to $1.6B, so I guess it is a success?

 

PEACEFUL PROTESTS (IN THE KEYSTONE STATE)- 4 MCOs that were not awarded LTSS contracts in the recent PA procurement promptly burned down their health plans. Uh – Sorry that was a bad initial report from CNN – I mean they submitted protests using the legal system in place. And you can understand why they protested – there’s a lot of money at stake. Those MCO contracts are worth an estimated $5.4B in annual revenue.

 

FARRIS’S FANTASTIC FRAUD FOLLIES– Unfortunately not enough room this week. I promise you can get your fix on our twitter feed.

 

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 (leaves are falling) 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 | la Patro sendis la Filon por savi la mondon

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2cz0jxc (this song is so depressing, but the video is important- pay attention to Amber alerts, people!)

Or you can click the one for optimist readers – http://bit.ly/2cyUfVy (Freddie still gives me goose bumps. And I still believe this song at every football game)

 

DO YOU REMEMBER WHERE YOU WERE WHEN THE TOWERS FELL? This Sunday will be the 15^th anniversary of the terrorist attack on the United States that killed 2,996 people and changed the course of history. I was asleep on a couch in the Southside of Birmingham, Alabama. I got woken up with a phone call from my father telling me to turn on the TV. Where were you? Write in in the comments or send me a note. Never forget. Teach your children.

THE INVISIBLE HAND (THE OTHER ONE, NOT ADAM’S SMITH’S)- MA is looking to cap MCO provider payment rates at 105% of FFS rates. Hospitals in MA currently claim they get 76% of the cost of care (then go out of business already and get into something you can make money in, if you’re really taking those types of hits!) under the non-capped setup. The hospitals claim that the cap would bring payments down to 56% of the cost of care.

TOUGH COUPLA WEEKS IF YOU’RE IN THE DIALYSIS SPACE –  A few weeks ago CMS took a shot over the bow (in a well done RFI-way, if you ask me) at how some providers jimmy with insurance for dialysis members to get higher payment rates. This week saw the KY Attorney General Andy Beshear (somebody tell me he’s not the previous Guvn’rs son…) take a shot at Fresenius, saying they promoted a harmful dialysis product to patients.

SAY IT WITH ME: CON-SOL-I-DAY-SHUN- New numbers out this week quantify what we in the space all know: the vast majority of MCO-covered lives are in a handful of plans. Roughly 43% of all Medicaid managed care bennies have a card from one of the top 5 national MCO outfits.

SHOW ME STATE DOES SHOW AND TELL- Telehealth in schools, that is. The Good Guvn’r Nixon signed a law to allow schools to bill Medicaid for teleconferencing physician services for students. The new funding approval is expected to help students with speech / language therapy and behavioral health needs the most. Rural areas have had a particularly hard time getting these types of specialists out to schools.

 

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. Jesus Villegas of Milford, CT extracted (he’s a dentist) $1.4M in fraudulent payments by using non-credentialed assistants to run up x-ray tabs for MA Medicaid. Great Nursing Care of Reynoldsburg, OH nabbed $4.9M in Medicaid overpayments using less than qualified providers (I see a pattern) and billings for unauthorized services. Owners closed shop upon receipt of the auditor’s letter. Oh, well – what’s another $5M in taxpayer dollars that just vanished into thin air? That’s just a drop in the bucket, nothing to see here. Move along. CVS in MA has agreed to pay Medicaid $800k for being so terrible at monitoring drug seeking behavior for opioid addicts (there was a system that tracked this, but CVS did not give its pharmacists access to it). Mr. Villegas, you win this week’s award. Awesome first name, by the way- but you do it dishonor.

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 (temps are dropping) 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 | de Vader de Zoon gezonden om de wereld te redden

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2c6pb2c

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

A BETTER WAY TO LOOK AT FRAUD IN MEDICAID- RoundUp readers and now show watchers know I can’t stand it when people essentially defend the huge disgrace of Medicaid fraud with the “I know its billions but that’s just a drop in the bucket in overall spending” or “but there is fraud in commercial and in Medicare, too!” A great article coming out of Illinois makes the (obvious) connection between Medicaid fraud (which we look the other way on) and Medicaid cuts (which we go bonkers about). Guess what- if you lose $12M on payments for dead people, you may have to cut some provider rates next year. (That article actually follows one family with a child who was counting on services and was directly impacted by Medicaid cuts that had to be made in part because of some large fraud losses). In other news, CMS released data on the improper payment rate for Medicaid (fancy way of saying fraud and stuff we can’t exactly call fraud). 2015 was 9.8% – that’s right, 10% of all Medicaid payments are “improper”, even by CMS’s own numbers – and it is projected to be 11.5% for 2016. For comparison, 2013’s rate was around 5%.

DON’T LOOK AT THIS CUP OVER HERE, LOOK AT THAT ONE OVER THERE! It was a rough month for ACA. The news of way higher than expected pmpm costs for those “healthier” expansion bennies was a punch to the gut, and the news of mass exchange exodus by the plans (I’m looking at you, Aetna) was the subsequent uppercut to the chin while ACA was bent over from the gut punch. Keep in mind some of the smartest people on our planet are investing their entire careers in ACA, so damage control was impressive (related vocabulary word – “sophistry”). Still hard to cover up some it, though. My favorite last week was an article that claimed expanding Medicaid keeps premium rates down on the exchanges. It’s a garbage argument, but works if you don’t ask too many questions. On a more positive note – if you are not following Slavitt on twitter yet, you need to. The head of CMS is tweeting constantly, and he’s honest, brilliant and engages people who disagree with him respectfully.

RUH-ROH IN ALASKA- After the fun sideshow that we all got to watch with Alaska’s expansion drama last year, a completely unexpected thing has happened. Expanding Medicaid has cost AK $30M more than projected. AK is now in the first stage of grief (denial), so consultants are trotting out the same old worn-out consolation theories: pent-up demand (previously known as the “woodwork” effect, until someone realized that was sort of a rude way to put it), costs will go down next year, et cetera.

KEYSTONE STATE SELECTS MLTSS MCO WINNNERS (FINALLY!)- Judging from all the calls I got on this one, a ton of RoundUp readers have been watching the procurement. Winners were AmeriHealth Caritas, Centene, and UPMC for You. 14 total bidders gave it a go, so expect some protests. In the meantime, congrats to the winners!

OK MEDICAID DIRECTOR LEAVING- Nico Gomez announced plans to leave the agency this week. Gomez has been at the helm during one of the toughest chapters in all of Medicaid history, with a particularly challenging budget reality in OK. Good luck, Mr. Gomez! Let us know where you end up.

 

FARRIS’S FANTASTIC FRAUD FOLLIES– Just not enough space this week. A few good ones in the twitter feed. Head on over there and get your fix.

 

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

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News that didn’t make it and sources for those that did: twitter @mostlymedicaid | Otec poslal Syna, aby zachránil svět

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

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

THE HEART OF IT ALL STATE WANTS BENNIES TO PUT SOME CASH IN THEIR PIGGY BANK- Ohio wants bennies to put the lesser of 2% of their income or $8.25 / month (or the cost of about 1.5 packs of cigarettes, which would get a chain-smoker through about 4PM one day) into a health savings account (which would be mostly funded by the state). Ohio number crunchers say the plan would save about $1B over 5 years compared to current spending. Whoa! A Medicaid “savings” number that means less actual dollars spent? Not some crazy “but we would have spent more if aliens landed and all enrolled in our program, so this plan “saves” money” savings estimate? The real kicker – bennies who can’t cough up the $8.25/month would be disenrolled. I give this 1 snowball out of 5’s chance (in Hell) of CMS not laughing this out of town.

 

KEYSTONE STATE CONTRACTS KINKED-UP OVER PROTESTS- All those new MCO contract awards we’ve all been watching the last 18 months in PA? Yeah, not gonna happen anytime soon. The latest round of implementations was supposed to start Jan 1, but a judge sided with Aetna this week on a move to delay until April. Aetna protested part of the state’s proposal review methodology. Now bidders have until August 22^nd to submit proposals under the restarted RFP process.

 

EMPIRE STATE OF THE SOUTH TELLS PROCUREMENT PROTESTORS TO STUFF IT- GA officials let the losers have their say (Americhoice, Humana and Amerihealth Caritas), but in the end said “no thanks, you still lose.” The new GA CMO (That’s an MCO everywhere else except GA) contracts were supposed to start this month, but now are delayed until at least August 2017. Losing MCOs can still take it to the courts if they want to (the current protests were handled by the state Dpt of Administrative Services).

 

AUDITOR TURNS OVER ROCKS IN OLD NORTH STATE, FINDS (INFERS) UP TO $17M IN NO-NO PAYMENTS FOR DME- For audit geeks nationwide, NC has been a hit parade of sorts the past few years. And the hits keep on coming. Beth Wood (the state auditor) took a national estimate of DME fraud rates and applied them to NC Medicaid claims to come up with the potential NC loss. Then she reviewed NC DMA payment review policies and said they weren’t up to snuff. A PCG post-payment review contract was also cited as an example of poor vendor management (per Wood, NC DMA staff did not do any verification of the PCG results).

 

NOT THAT ANYONE’S WATCHING, BUT BLUE-GRASS STATE EVIL PLAN TO ROLL-BACK EXPANSION MISSED FIRST DEADLINE- The Good Guvn’r Bevin’s office missed an internal deadline related to submitting its infamous 1115 waiver to CMS this week. Reason cited? Way more comments than expected.

 

CONGRATS DUE TO ADVANCEMED- They just want a $77M contract from CMS to provide fraud consulting. Congratulations!

 

WELLCARE BOOSTS M&A TEAM- Tuesday’s earnings call was encouraging for those of us excited to see the WC comeback into the Medicaid space continue. CEO Ken Burdick focused on criteria for targets in both the Care’ and Caid’ spaces (and largely avoided speculation around the WC role in the event of a breakdown in the Anthem/Cigna deal).

 

FARRIS’S FANTASTIC FRAUD FOLLIES– Just not enough space this week. Plenty in the twitter feed, I promise. Head on over there and get your fix. My favorite this week is probably either the St.Joes story or the Tenet one.

 

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 (I got lemongrass plants on clearance for $1 this week!) and keep running the race (you know who you are).

—-

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

 

News that didn’t make it and sources for those that did: twitter @mostlymedicaid | Otac je poslao Sina da spasi svijet