Category: Curator

HHS Curator is our free research service published by our team. We read hundreds of Medicaid news items each week and highlight and summarize them for you to save you time.

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Info of hundreds of Wisconsin Medicaid members may have been exposed

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A data breach in Wisconsin may have revealed personal health information of 1,200 members.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

(WCAX)

MADISON, Wis. (WBAY) – The personal information of hundreds of Wisconsin Medicaid participants may have been exposed.

Gainwell Technologies LLC has announced that an “unauthorized individual” gained access to an account on Oct. 29, 2020. The tech firm says that may have exposed names, member identification numbers and billing codes.

Gainwell provides services to the Wisconsin Department of Health Services Medicaid Program.

On Jan. 15, notifications were sent to 1,281 Wisconsin Medicaid members who may have had their information exposed.

These members are being offered free credit monitoring for one year.

The hack was discovered on Nov. 16. Gainwell says it has been working with DHS to prevent future incidents.

 
 

Clipped from: https://www.wsaw.com/2021/01/15/info-of-hundreds-of-wisconsin-medicaid-members-may-have-been-exposed/

 
 

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Artificial intelligence machine was able to dupe Medicaid.gov

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A bot submitted half the public comments on a proposed Medicaid program change.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

Deepfake text manipulation has the power to throw governmental agencies off, a Harvard medical student has shown.

Public feedback is a crucial element of shaping and carrying out state and federal level programs. Your responses, as a civilian, inform how these governmental agencies go forward (or not) with policy decisions. At least, that’s what the idea of public feedback is based on. But deepfake text manipulation — just like deepfake videos and photos — has the ability to dupe even the smartest of observers, Wired reports.

A Harvard medical student named Max Weiss proved this in 2019. Back then, Idaho had plans to change its Medicaid program. It needed federal approval to do so, which required public input fed into Medicaid.gov. The state government sought public responses and became Weiss’ little science experiment, in which he used an OpenAI program, GPT-2, to generate nearly-believable responses on the issue. Out of approximately 1,000 comments put into Medicaid.gov that round, half of them came from Weiss’ artificial intelligence machine. When he asked volunteers to differentiate between the real and fake ones, Wired says the volunteers “did no better than random guessing.”

The nightmare of automated responses — With its sophisticated and advanced language system, Weiss’ bot created responses that had no problem sneaking under Medicaid.gov’s radar.

It’s not a particularly difficult undertaking. The bot is repeatedly trained on human speech, phrasing, grammar, and syntax. It then tries to emulate that speech and create its own iterations in real-time. In response to the experiment of being duped by artificial intelligence, the Centers for Medicare and Medicaid Services assured the public that the agency had implemented security programs to block such manipulation.

The need for manipulated text-detection tools — Image and text generation by artificial intelligence can be hit or miss. Sometimes the results are odd and creepy (like this bot that took captions and tried to create photos from them). Other times, these experiments can lead to silly or cute results. But deepfake text manipulation opens a host of security and privacy threats for not only governments but also everyday internet users.

Automated text campaigns have caused headaches for the federal government even before Weiss. In 2017, the Federal Communications Commission found that more than a million responses sent over net neutrality weren’t real.

As these bots get more advanced with intensive training, cybersecurity analysts will have to work on manipulated text-detection tools and programs that can spot the real input from the fake entries. In the era of political misinformation that has led to mass polarization and people believing conspiracy theories, these agencies can’t afford the potential pitfalls of not getting out in front of this problem.

 
 

Clipped from: https://www.inputmag.com/culture/artificial-intelligence-machine-was-able-to-dupe-medicaidgov

 
 

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Colorado public option bill sponsor says the proposal will be reintroduced this year

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The Colorado public option is back on the table, with perhaps a few changes since we last saw it in March 2020.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

The Colorado Senate sponsor of last year’s public option health insurance proposal said that she definitely plans to resurrect the idea in the soon-to-convene 2021 legislative session, though she acknowledged that details could be different from the derailed 2020 effort.

Sen. Kerry Donovan, D-Vail, seemed to quell speculation that Democrats might be moving on from the idea when she said during the Denver Metro Chamber of Commerce legislative preview event Tuesday that she and sponsoring Rep. Dylan Roberts, R-Avon, are “in the initial phases” of drafting a new bill. And while Donovan, the Senate president pro tempore, didn’t offer details as to how this new proposal would be shaped, she did say that it “will look different than last year’s bill.”

The 2020 proposal would have required any insurer offering private plans within a county also to offer a public option plan that kept premiums below market rates by reimbursing health care providers at 155% of Medicaid rates — a level much lower than many now charge. Colorado Hospital Association leaders opposed the bill, saying that it would weaken the state health care system by taking money out of it, and business leaders were concerned that it would shift the cost of care to people in private employer-provided plans.

That bill received approval from its first legislative committee the week before the state declared the coronavirus pandemic to be a public health emergency, and it was shelved after the Legislature adjourned for more than two months, as officials sought to concentrate on limited Covid-focused bills upon their return. After the 2020 session, several Democratic leaders implied that they would need to rethink whether it was part of future reform efforts, but Donovan and House Speaker Alec Garnett both seemed to say Tuesday that it will be part of a renewed focus on ways to lower health care costs for more Coloradans.

Sen. Kerry Donovan, Rep. Dylan Roberts and Rep. Chris Kennedy present the Colorado Option bill in 2020.

Jensen Werley

Clipped from: https://www.bizjournals.com/denver/news/2021/01/12/colorado-public-option-health-insurance-donovan.html

 
 

 
 

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CMS Releases Guidance on Funding for SDH Programs

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The 51-page new guidance layouts several details CMS will use to assess whether state programs are complying with Medicaid rules re: addressing non-healthcare costs.

 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 

 

Clipped from: https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf

sho21001Download
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Worth the Read?: The Path Forward (UnitedHealth Group, September 2020)

This article is part of our whitepaper review series called Worth the Read?, where we boil down HHS industry whitepapers. We believe most whitepapers have little value beyond marketing the producer’s services, and we want to save you time in sorting through what is or isn’t Worth the Read.

Whitepaper Reviewed

UnitedHealth Group: The Path Forward to a Next-Generation Health System

A four-page quick read.

The Gist

Cynical view- A health insurer wants more people to have health insurance. Idealist view- A health insurer in a unique position to have broad impact is putting forth new ideas in advance of significant federal change under an incoming Biden administration.

Key Points

UHG breaks up its overall vision into 4 major objectives:

  1. Achieve universal coverage
  2. Improve health care affordability
  3. Enhance the healthcare experience
  4. Drive better health outcomes

Overall Assessment of Value – WORTH THE READ

Overall this whitepaper is strong on specifics across both Medicaid and exchange verticals. There is solid quantification of multiple pieces of their objectives. And to be honest its pretty interesting to have a behemoth the size of UHG telegraph this type of strategy.

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Dickson Co. Woman Charged with TennCare Fraud

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TN mother falsely reported she had custody of her so that she could get Medicaid benefits. $9,000.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

 
 

 
 

NASHVILLE, Tenn. – A Dickson County woman is charged with TennCare fraud and theft of services for allegedly falsely reporting that she had custody of her son in order to obtain TennCare benefits for herself.

The Office of Inspector General (OIG), in a joint effort with the Dickson County Sheriff’s Office, today announced the arrest of 31-year old Megan Hood of Dickson. Both charges against her are class D felonies.

Investigators allege that Hood falsely reported that she had custody of her son in order to receive TennCare benefits for herself.  As a result, the state says TennCare paid more than $9,000 in fees and claims on her behalf.  

“Lying in order to wrongfully receive TennCare benefits will not be tolerated,” Inspector General Kim Harmon said. “Our agency diligently investigates these situations in order to preserve Tennessee’s Medicaid resources for those truly deserving.”

The case is being prosecuted by District Attorney General Ray Crouch of Dickson County.

The OIG, which is separate from TennCare, began full operation in February 2005 and has investigated more than 5,760 criminal cases leading to more than $10.8 million being repaid to TennCare, with a total estimated cost avoidance of more than $163.6 million for TennCare, according to latest figures. To date, 3,100 people have been charged with TennCare fraud.

Through the OIG Cash for Tips Program established by the Legislature, Tennesseans can get cash rewards for TennCare fraud tips that lead to convictions.  Anyone can report suspected TennCare fraud by calling 1-800-433-3982, toll-free or by logging on to www.tn.gov/oig/ and following the prompts that read “Report TennCare Fraud.”

 
 

Clipped from: https://www.tn.gov/finance/news/2021/1/5/dickson-co–woman-charged-with-tenncare-fraud.html

 
 

 
 

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The U.S. and Tennessee resolve claims worth $1.72 Million

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A group of TN doctors got paid by Medicare and TN Medicaid for an implantable acupuncture device that was not covered.

 
 

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

 
 

 
 

The exterior of the United States Department of Justice on Feb 16, 2018 in Washington, D.C.

ALEX EDELMAN/AFP/Getty Images

NASHVILLE (WSMV) – Don Cochran, U.S. Attorney for the Middle District of Tennessee, and Herbert Slatery III, Attorney General for the State of Tennessee, announced today that they have settled claims between three providers for false liability under the False Claims Act for the alleged improper billing for electro-acupuncture using a peri-auricular stimulation device known as “P-Stim” that does not qualify for reimbursement under Medicare or TennCare. 

James P. Anderson, M.D. (“Dr. Anderson”), owner of Affiliated Neurologists, PLC; Charles F. Spencer, D.C., owner of Total Family Physicians Center PLLC d/b/a Total Family Health & Wellness (“Total Family”); and Mitchell P. Shea, D.C., owner of Chiro2Med of Tennessee P.C. (“Chiro2Med”) agreed to pay a combined $1.72 million to resolve liability. 

P-Stim is an electro-acupuncture device that, pursuant to manufacturer’s instructions, is affixed behind a patient’s ear using an adhesive.

Once activated, the device then provides intermittent stimulation by electrical pulses.

Medicare and TennCare do not reimburse for such acupuncture devices, nor do Medicare and TennCare reimburse for P-Stim as a neurostimulator or as implantation of neurostimulator electrodes. 

From May 2016 through November 2018, Dr. Anderson, Total Family, and Chiro2Med billed for, and were reimbursed by the United States for acupuncture using P-Stim devices under HCPCS Code L8679, which instead requires implantation of a neurostimulator with anesthesia in a surgical setting by a physician, typically a surgeon.  Dr. Anderson, Total Family, and Chiro2Med separately billed for, and were reimbursed by, Medicare and/or TennCare for these devices over a two year period.  

On June 10, 2020, Tennessee brought suit in the Chancery Court of Davidson County against Dr. Anderson under the Tennessee Medicaid False Claims Act for the false claims he submitted to TennCare.

Under the terms of the settlement, Dr. Anderson agreed to pay $1 million to the United States and Tennessee over five years.

Dr. Anderson also agreed to enter into an Integrity Agreement with the Office of Inspector General of the U.S. Department of Health and Human Services that will require regular monitoring of its billing practices for a period of three years.

Dr. Spencer and Total Family agreed to pay the United States $700,000 over five years.

Dr. Shea and Chiro2Med agreed to pay the United States $20,000 over five years.

“These settlements are part of a nationwide effort to hold accountable those providers who were paid improperly for non-reimbursable acupuncture under the guise of a surgically implanted neurostimulator,” said U.S. Attorney Cochran.  “Working closely with our partners at CMS’s Center for Program Integrity, the Department of Health and Human Services Office of the Inspector General, our sister U.S. Attorney’s Offices, and the Tennessee Attorney General’s Office, we were able to identify those who profited from the submission of these false claims and negotiate resolutions that resulted in a significant recovery of taxpayer dollars.”

“This Office will not tolerate medical device fraud in Tennessee, whether it is the P-Stim as in these cases, or any type of fraud,” said General Slatery.

These cases were handled by the United States Attorney’s Office for the Middle District of Tennessee and the Tennessee Attorney General’s Office, Medicaid Fraud and Integrity Division, with assistance from the Tennessee Bureau of Investigation Medicaid Fraud Control Unit and the Department of Health and Human Services, Office of Inspector General.  Assistant U.S. Attorney Kara F. Sweet represented the United States.  Deputy Attorney General Tony Hullender represented Tennessee.

 
 

Clipped from: https://www.wsmv.com/news/the-u-s-and-tennessee-resolve-claims-worth-1-72-million/article_5155c642-4ed3-11eb-8c84-03fb1e524dbc.html?block_id=998344

 
 

 
 

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AG’s Office: Gallup agency owner pleads guilty to Medicaid fraud

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A New Mexico personal care agency owner falsified billings for her employees.

 
 

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

 
 

 
 

SANTA FE, N.M. (KRQE) – The New Mexico Office of the Attorney General reports that it has secured a guilty plea from Lolita Begay-Yazzie to one count of fraud in excess of $20,000 and one count of failure to retain documents for defrauding New Mexico’s Medicaid program of over $40,000. According to the Office of the Attorney General, Begay-Yazzie owned and operated a personal care agency in Gallup, New Mexico.

“Medicaid ensures that almost half of all New Mexicans have access to healthcare, and we must do all we can to protect these resources that are so vital to our families,” said Attorney General Hector Balderas. “We will continue to hold anyone who tries to steal these critical healthcare resources accountable.”

In a press release, the Office of the Attorney General states that Begay-Yazzie billed New Mexico Medicaid as if her employees were providing care services in excess of 24-hours a day. Begay-Yazzie is also accused of overbilling Medicaid for more services than each patient required to meet their needs according to their care plan.

The AG’s Office says that Begay-Yazzie made withdrawals at ATMs in casinos in excess of $85,000 from the personal care agency account. The court has ordered a pre-sentence report and is said to hold a sentencing hearing in the coming months.

According to the terms of the plea, Begay-Yazzie is facing up to five years of incarceration and will be excluded from providing any Medicaid services in the future. The Office of the Attorney General’s Medicaid Fraud Control Unit investigated and prosecuted this case.

Clipped from: https://www.krqe.com/news/crime/ag-gallup-agency-owner-pleads-guilty-to-medicaid-fraud/

 
 

 
 

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CMS issues guidance for state Medicaid SDOH programs

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CMS guidance on priority focus areas for SDH efforts in Medicaid is now out.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

CMS issued a new guidance for state officials looking to roll out social determinants of health strategies for Medicaid and Children’s Health Insurance Program members.

The guidance, released Jan. 7, focuses on how state Medicaid directors can use flexibilities under federal law to design programs that decrease healthcare spending and improve outcomes through addressing social, environmental and economic factors.

CMS’ guidance focuses on housing projects, nonmedical transportation, meal delivery, education and employment support, among others. 

View the full guidance here.



Clipped from: https://www.beckershospitalreview.com/payer-issues/cms-issues-guidance-for-state-medicaid-sdoh-programs.html


 

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Appeals Court Upholds Trump Rule Requiring Hospitals to Show Prices Upfront

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Despite industry opposition, hospitals will now have to report the prices they accept from insurers as payment.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

The U.S. Court of Appeals for the D.C. Circuit on Tuesday upheld a Trump administration rule that requires hospitals to disclose the prices they negotiate with insurers for a range of health tests and procedures.

The 2-0 decision by the appeals court means that American patients will have access to hospital pricing information starting on Jan. 1, 2021, helping them find the lowest costs and the highest quality of care when deciding on treatment.

“This transformative hospital price transparency rule has been fought at every step by the swamp and defenders of the status quo,” White House Press Secretary Kayleigh McEnany said in a statement.

“Today’s ruling should reassure the American people that President Donald J. Trump refuses to bow to the influence of special interests who would prefer to keep patients in the dark. This initiative is just one in a series of rules that will bring unprecedented price transparency to all elements of healthcare,” she added.

The Centers for Medicare & Medicaid Services (CMS) issued the transparency rules in November 2019, calling on hospitals to make public the often-secret rates that they negotiate with insurance companies for all services, drugs, and supplies. The Department of Health and Human Services (HHS) said in a statement at the time that hospitals must make public all standard hospital charges in a single data file.

The moves came as a result of Trump’s signing of an executive order in June 2019 over price transparency.

Hospitals, insurer organizations, and advocacy groups objected to the rules, and said that the Trump administration did not have authority to require the disclosures, which they held to be trade secrets. The hospitals also disputed that the policy would benefit consumers and lead to lower costs, arguing that compliance would instead be too burdensome and interfere with their care for patients.

The finalization of the rule prompted the American Hospital Association (AHA) to file a legal challenge. They argued that the White House didn’t have the authority to make the rule and in doing so had violated the First Amendment in its creation, and had acted in an “arbitrary and capricious” manner.

A federal judge ruled on June 23 that the Trump administration rules were legal. But the groups appealed on Oct. 15.

In the appeal, the groups said that the price transparency rules would pose a “herculean” and costly task of compiling health care costs, while reducing competition and causing confusion about patients’ out-of-pocket expenses.

Circuit Judge David Tatel, however, said concerns about the burdens “miss the mark,” and pointed to HHS Secretary Alex Azar’s findings that greater disclosures would benefit the “vast majority” of consumers and likely result in lower—not higher—prices.

“The Secretary weighed the rule’s costs and benefits and made a reasonable judgment that the benefits of easing the burden for consumers justified the added burdens imposed on hospitals,” Tatel wrote.

The latest decision upholds the June 23 ruling by U.S. District Judge Carl Nichols.

Melinda Hatton, the AHA’s general counsel, said the group was disappointed and hopes that a potential Biden administration would revise the rule and exercise “enforcement discretion” until the CCP (Chinese Communist Party) virus pandemic runs its course.

On Twitter, Azar praised the decision. “Big win for American patients today. The DC Circuit ruling is another major victory for President Trump’s transformative healthcare agenda. Starting January 1, Americans will have access to the actual prices paid for the most common hospital services,” he wrote.

The U.S. Chamber of Commerce supported the hospital groups, saying the rule could cause hospitals to demand higher prices for their services if they saw other hospitals charging more.

The case is American Hospital Association et al v. Azar, D.C. Circuit Court of Appeals, No. 20-5193.

Janita Kan and Reuters contributed to this report.

Clipped from: https://www.ntd.com/appeals-court-upholds-trump-rule-requiring-hospitals-to-show-prices-upfront_546698.html