Category: Amazing Free Content

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2Buu4Ni

For optimist readers- http://bit.ly/2BqY5h7

MICHIGAN MOVING PBMS TO THE DOGHOUSE- So it seems that all the news of spread pricing these last 2 years or so has made people a little skittish on PBMs. Michigan Medicaid announced plans to nix its PBMs starting December 21 (interesting start date). At that time the state will take over management of drug benefits and save an estimated $40M. The change comes about 6 months after the Michigan Pharmacists Association rallied behind reports of PBM pricing shenanigans, including some that showed the state overpaying PBMs by $64M.

KEYSTONE STATE MOVING TO SINGLE PDL– All 8 PA MCOs will start using a single preferred drug list Jan 1 2020. The change was triggered by high Hep-C costs as well as an effort to help providers managing care for members with multiple drug regimes. State officials think this will save about $85M each year. Here’s the kicker- the earlier MCOs analysis said it will cost the state $81M each year. If you’ve ever tried to follow Medicaid Rx math you know its all witchcraft, so its not surprising that the MCOs and state came up with entirely different numbers.

WONDERS NEVER CEASE: FEDERAL JUDGE STOPS REGULATIONS PROMULGATED UNDER NORMAL LEGAL PROCESS– I think I have seen this movie before. If you followed the drama of the Public Charge Rule the last few months, you probably knew this was where we would end up. The Trump Administration promulgated rules that would enforce existing law (that requires those asking for admission into the U.S. to prove they will not require safety net services or have someone who can cover their costs. Very similar to what I found out when I wanted to move to Scotland in the late 1990s). The proposed rule made it all the way through the established, legal process- until it was rejected by 2 judges (1 in the southern district of NY and 1 in CA) who decided the right thing to do was to continue to not enforce existing law. My high school civics class really misinformed me about how the three branches of government work.

IDAHO CONSIDERING MAGIC MONEY POOL TO PAY FOR VOTER-APPROVED EXPANSION- And it looks like they will find it hiding in county coffers. Committee leads tasked with passing the hat are eyeballing $10M in county funds that they think are now fair game for Medicaid (since those funds currently go to uncompensated care, and Medicaid will now cover that). My prediction – these funds will be bundled with the disappearing tobacco settlement funds and get matched with the federal magic money cover expansion costs for about 6 months. That will grease the skids needed to get the initial vote done. Then we will hear about a huge Medicaid budget shortfall about 8 or 9 months into the expansion.

MORE NEWS STORIES OF MEDICAID PAYING COSTS FOR DEAD PEOPLE- This week its Minnesota with an estimated $3.2M owed back to the feds. Out of 100 sample capitation payments, 95 had unallowable payments. You can guess the answer by now – that this was during a transition to a new eligibility system, and we promise the new one won’t do the silly things the old one did (see also LA).

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award. Our first fraudster hails from Conway, Arkansas: Karen Todd was popped this week for billing $600k in bogus optometrist claims for her husband (Karen is the office manager; hubby the optometrist). Let’s stay in the south a moment and head to Raleigh, NC where we find Pamela Faulkner. Pam buddied up with Renee Borunda to steal $213,927 in Medicaid bucks. How? Bogus behavioral health services claims. Southerners continue to be represented this week as we head to Nashvegas. There we find Michael Kestner, Brian Richey, Daniel Seely and Jonathan White stealing a cool $100k from Medicaid (they tried for $8.6M but came up short) and another $5.3M from Medicare and TriCare. Their scheme involved rev max and fraudulent claims at their pain clinic. Ok let’s leave the south and head to Texas (its different, I promise). Omar Cuate Canales of Rio Grande City  plead out this week to $385k in Medicaid thievery using his DME business. Now its time to head to the heartland. Tracy Wellendorf of Cedar Rapids, Iowa agreed to pay back the $1M he stole from Medicaid using medically unnecessary sinus surgeries. Wellendorf agreed to pay back the $1M as a double-dog promise he did nothing wrong, but we all know something smells funny here (get it? Smells funny? Sinus surgeries…). Mrs. Todd you win this week’s award. Congratulations! Maybe you and hubby can take a nice vacation somewhere? I wanted to give this to Mr. Wellendorf, but since he wrote a big check to get the state to pretend he did nothing wrong, and I don’t want to get sued- Mr. and Mrs. Todd win! Taxpayers, you lost about $7.4M in that last paragraph.

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (make your first fire of the year if its cold enough wherever you are) 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: de Vader zond de Zoon om de wereld te redden

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/33w0dQN (this video from 1973 is amazing; and these guys are still touring)

For optimist readers- http://bit.ly/2MA1lvT

SUE TO GET RATES YOU WANT (WHERE DO I SIGN UP FOR THIS DEAL?)- Alaska “providers” (hospitals and nursing homes, for those fooled by this label. It ain’t Doc Brown making house calls) successfully used the judiciary to keep their pay rates above the law. The law being the process used to govern budgets in the state, including cuts. See, The Good Guvn’r Dunleavy vetoed (that’s a legal power executives have) about $50M in state Medicaid spending. So, the agency has to enact those cuts. Well, “providers” whose revenue streams depend on those Medicaid funds didn’t like it and got a judge to undo the legal process. I think I’ve seen this movie before, but in a different theater…

IOWA STILL LOOKING FOR 3^RD MCO- In case you missed it United submitted its Dear John letter earlier this year. The Medicaid Director commented this week on plans to issue an RFP for a replacement MCO, but no timetable is in place yet.

NH AND FEDS AT ODDS OVER SCHOOL BASED MEDICAID PROGRAM- The Good Guvn’r of The Granite State sent a re-assuring letter to school superintendents late September. Why? Because new CMS guidance looks to make sure only services covered under the state Medicaid plan can be paid for by Medicaid in schools. Someone tell me what I am missing, but can’t this just be fixed with a state plan amendment adding any outlier services into the covered mix? And does anyone have an estimate of how much Medicaid has paid for non-covered services in schools over the years?

GOOD GUVN’R CUOMO TAKING BRIBES IN UKRAINE? SORRY, IN NY– At first I thought this was just a slimy attack from one of those (clutching pearls as I say/type this) right-wing news organizations, but turns out its in the very trusted, totally-not-fake-news NYT. Seems Mr. Cuomo was asking for big donations from the state Hospital Association during his tough campaign last year. And once those payments came through, voila– higher Medicaid rates for hospitals! (and other providers, but in keeping with modern “journalism” I chose to emphasize the implication I wanted make vs the broader context).

CONGRATS TO OUR FRIENDS AT i2i- Big news late last week that i2i and Cerner are teaming up to integrate the power of their platforms. If you’re not familiar with i2i Population Health, they are now in 2,600 systems in 36 states providing various population health management solutions.

IDAHO JOINS THE GROWING RANKS OF WORK REQUIREMENTS STATES- The public comment period on Idaho’s work requirements plan (paired up with its Medicaid expansion rollout) is now open. Get ready to be called lots of names, Gem State friends.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award.  San Juan EMS will pay $350k for stealing from Puerto Medicaid with 400 medically unnecessary flights. Pamela Van Drie and hubby Lorin G. Van Drie of Springfield, MO will serve 5 to 10 years for stealing $885k. Their crimes? Providing dental patients with mouthpieces that cost $50, and then billing Medicaid $700 for “speech aid” prosthetics. The lovebirds also (successfully) billed Medicaid for dentures for patients who were not even on Medicaid (extra points!). Kathleen Service (actual last name- great name for a social worker if you ask me) of Hartford, CT stole $151k using other providers’ billing info. CT stopped allowing social workers to bill in 2017, but Ms. Service disagreed and decided to bill anyway (just with other people’s IDs who were still allowed to bill). Paul Peterson of Phoenix, AZ was indicted this week on charges of human trafficking and Medicaid fraud. His crime? He used his position as an elected official to traffic 28 pregnant women from the Marshall Islands to come to the US and sell their babies via an adoption scheme. The Medicaid connection- he also helped them get $814k in Medicaid benefits. Fly back east to Norfolk, VA to check in on Houman Motti. Mr. Motti will go to federal prison for using his ambulance company to steal $63k in Medicaid bucks. There is a lot of strong competition for this week’s award- what’s that? This just in from the judges booth: Mr. Peterson wins this week’s award! His total dollar impact was slightly less than the Van Drie’s, but he gets extra points for abusing his elected office to commit heinous crimes.

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 finally rained here!) and keep running the race (you know who you are).

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

Trystero: ‘ursil alab alaibn li’iinqadh alealam

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2o4qSFl

For optimist readers- http://bit.ly/35g3pBM  (read the comments on this one. Will make you smilecry)

AND SO IT BEGINS- Walmart opened its first “super center for healthcare services” in GA a few weeks back. Can you imagine what Medicaid spending will be like once Walmart is an enrolled provider? Will we be getting roll-back pricing on imaging, physician services and lancets? I sure hope so.

KEYSTONE STATE TRYING TO WORK OUT WORK REQUIREMENTS– Despite The Good Guvn’r Wolf’s veto-ing similar bills twice, reps in the PA state house are spinning up another work requirements bill. The main talking point that could get this one legs is from Sen. Martin of Lancaster County –  “This program, last year, grew by over one billion dollars. If it keeps growing at the pace it’s growing, the program is not going to be sustainable.” Mr. Martin, don’t you know Medicaid is different? Every time a Medicaid claim is paid, a Bitcoin is mined in the MMIS subsystem, thus creating new value. Medicaid is actually a money maker, sir. Get with it!

GA TRYING TO MAKE NEMT PERMANENT/ FOR REALS– While some states are relieved they don’t have to shell out millions for NEMT anymore (as CMS regs will likely make it optional soon), of course the low-informed press paints all this as “rolling back protections.” For those not familiar with NEMT, that’s non-emergency transportation- a benefit that costs $3B+/year. Its important, but also riddled with fraud and often crappy execution. Some states (particularly those with decent public transport) have already gotten approval to not have to pay for it. But I digress (into things like “details” and “balanced information”)- PeachState lawmakers are trying to get a bill that makes it state law to have to pay for it regardless of what the federalis do.

WE PROMISE THE NEXT $8B WILL TRANSFORM IT FOR REAL THIS TIME– NY’s first DSRIP waiver was focused on reducing hospital admissions by 25% (that did not happen). The next big idea being pitched to CMS (you have to have an idea that at least some sucker will buy; you can’t just come out and say the truth that you just need more and more and more Medicaid moula to keep the chaos going) is that the next $8B will move more payments into Value Based Contracts. Keep in mind the first version touted its aggressive move to value based contracts (something like 80% by 2020 I think). Value Based Contracts is now akin to “abracadabra”. Or, more accurately, “open sesame.” Waivers typically go about 5 years at a time (and are never not renewed), so my prediction is this one gets approved and in 2025 we will hear again that same abracadabra (value based contracting) and again open that sesame (another $8B+ spend).

AETNA SAYS NC SCORING SYSTEM UNFAIR- Aetna lost by a tiny percentage of points under the NC managed care RFP scoring system (there are many issues inherent with this procurement approach – hop on one of our monthly webinars to hear about them). But a new thread has emerged in which Aetna is complaining that one of the state scorers lives with a BCBS (a winner) employee. Best I can tell that’s the extent of their “unfairness” argument. And if NC is anything like AL (where I live), you can’t shake a dead cat (or stick or something. I can’t keep up with who is or isn’t offended by which version of that analogy; is that even an analogy? Is anyone really offended by it, anyway? Or do I just assume they are? Is that in itself offensive? Please members of the online outrage/cancel culture let me know in the comments) without hitting a BCBS employee. They are large employers in many states is what I’m saying.

CMS GETS NEW FRAUD TEETH- Its really hard to believe we will ever stop the flagrant fraud in Medicaid, but this is a new blip on the radar. CMS issued a final rule last week that lets them exclude providers in new ways and for longer periods of time. The gist is that docs with affiliations with parties with one or more disclosable events can now be nixed from the Medicaid funding gravy train (all these terms, with the exception of gravy, are defined in the reg here. For a solid gravy recipe, visit here). Under the new reg, docs can be banned from Caid for 10 years for the first offense (its now 3) and 20 years for the second offense.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award.  Joseph Kimble of Longview, TX plead guilty earlier this month to using his company Tiger EMS to steal $750k (via bogus non-necessary ambulance rides). Skip on up to Union City, NJ and we find Alex Fleyshmakher, Reuben Sevumyants, Samual Khaimov and Yana Shtindler getting nabbed for stealing $99M from Care and Caid. What are they charged with? Using their pharmacies to get paid for scripts they never gave to patients and bribing doctors to help out with the scheme. Let’s head south to VA Beach, where we find Udaya Shetty pleading to stealing $460k for double, triple and quadruple booking patients and getting paid for it by Medicaid. Mr. Shetty (a therapist/psychiatrist) would spend about 5 minutes with patients, write a script and then herd the next one in. He then had his staff bill as if he had spent 40 minutes with each. While the total fraud on this one is $460k, Caid got taken for $161k, Care for $169k, TriCare for $72k and BCBS for $62k (kudos to the journalist for separating that out in the story). Keep heading south to Hotlanta, where Diandra Bankhead stole $1.2M of your tax dollars using a home health scheme involving medically fragile children. Her company “Elite Homecare” submitted 5,400 bogus claims to Medicaid. Head up to Balto (still below the Mason-Dixon line, though) to meet Celeste Bland-Guary. Celeste plead guilty to using her counseling business to steal $82K in Medicaid bucks. All things considered, the award this week goes to the Four Caballeros in Union City! We don’t yet know how much of the $99M they stole will turn out to be from Caid, but it will almost certainly end up being more than the other candidates!

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 must surely one day rain, mustn’t 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: hav shlach levn latil at aavalm

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2MaW5ia

For optimist readers- http://bit.ly/2M8fsbh

IN CASE YOU HAVEN’T HEARD, THERE’S A DELAY IN NC- Well all you naysayers telling me you heard whispers of a delay back in August were right. It’s official, we have our first delay in the NC move to managed care. The Good Guvn’r Cooper is throwing a hissy-fit over this everyone-agrees-its-the-answer-to-all-our-problems-Medicaid-expansion thing, and he took his toys and went home when those “other” reps (voted in by some very deplorable people in a Russian-rigged election, I’m sure) were not so excited about a possible increase to the already murderous Medicaid cost trends [insert foolish, but confident economic theory here about “losing out on free federal money”]. Translation: Cooper fouled up the funding for managed care startup costs because he couldn’t get his way and score political points on Medicaid expansion. What was to be Phase 1 in November, will now be Phase 1 and 2 simultaneously in February. The Medicaid agency team is doing a great job of managing the chaos – but there’s only so much Cooper a successful transition can handle. He may end up being placated anyway- as of yesterday the house passed a gravy-train (Medicaid expansion) bill. That bill would expand under the pretense that work requirements and related premiums will be implemented. And we all know how that will turn out (just ask NH in case you have any questions).

MICHIGAN MCO MERGERS- Priority Health will gobble up Total Health Care. The gobbler has about $4B in revenue over 830k covered bennies; the gobble-ee has about $365M over 53k covered Medicaid members (96k total). To help grease the regulatory skids, Priority will be dropping $25M into a foundation to “fund a variety of non-profit initiatives” in Detroit.

FOSTER CARE IN ILLINOIS- IL DFCS is working to move 74,000 foster kids into managed care and some reps are raising concerns. The gist of the concerns are related to a rocky experience with MCOs in general. Here’s an idea you IL knuckleheads- actually pay the MCOs and it might turn out better (see previous reporting on how IL gets sued every 6 months or so and is forced to pay MCOs BILLIONS of dollars it reneged on). Here’s another idea- do a real audit of the quality of care for those foster kids now to see how well you are doing in the absence of managed care.

AL LAUNCHES ALABAMA COORDINATED HEALTH NETWORK (ACHN)- The state launches an expanded care coordination program October 1. About 750k bennies will begin to receive services designed to better manage their care. Childhood obesity, infant mortality rates and substance abuse are the top 3 targets of the new program.

AFTER THREE DECADES OF OPERATION, FEDS DECIDE TO TRY AND CONFIRM LIFELINE SUBSIDY ELIGIBILITY FOR REALS- If you are not familiar with Lifeline, it’s a $10/month subsidy for low income folks to get a cell phone. For 34 years you have been able to get one if you are eligible for Medicaid. Actually you have been able to get one if the phone carrier (who makes money if you are deemed eligible) says you are Medicaid-eligible. So now the feds decided to start verifying that with an independent system. An OIG audit found that 36% of bennies could not be verified as eligible back in 2017. Keep smiling while you pay for all this fraud, dear taxpayer.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award.  Felicia Blount of Gary, IN got 12 months in the slammer for stealing $195k Medicaid bucks. Her and her momma both falsified bills to Medicaid for transporting Medicaid patients to appointments. Dang, Felicia! Head on up (over?) to Columbus, OH where James McFadden was convicted of stealing $258,000 from Medicaid by faking PTSD and pretending he could not talk. His charade also required him to wear diapers. His co-conspirator got paid as his personal care aide to help with his bogus condition. Go west and we find 34 people in CA, AZ and OR nabbed in a $257M Medicare and Medicaid fraud scheme. The fraudsters used various means involving medically unnecessary tests and prescriptions.  And finally (there are at least a dozen more on my desk I could write about this week, I just need to land this plane)- let’s fly back to the heartland to check in on Craig Barnett of Nebraska. Barnett is a former Medicaid auditor now serving jail time for stealing $277k using his father’s power of attorney. He used that power to take SSI monies, raid mutual funds and falsely obtain nursing home coverage (which is where the Medicaid part comes in) for his father. He was head of the NE Medicaid Audit and Financial Support Division the whole time. Mr. Barnett, I hope you can come to some sense of right and wrong as you stare at those prison bars. But in the meantime, you win 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 (assuming you don’t find yourself suddenly living in a parched desert like I do) 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: батько послав сина, щоб врятувати світ