Category: Amazing Free Content

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2Y8ReSk

For optimist readers- http://bit.ly/2Y93BOl

AND SO IT BEGINS (MCO ENROLLMENT IN NC)- Open enrollment for the first ever Medicaid managed care plans in the Tarheel State began this week. 540,000 members in 27 counties can pick their insurance cards until September (if they don’t pick, one will be picked for them). There could be a monkey wrench though- the MCO rollout costs about $200M in start-up money. And that money is tied up in fights over the current state budget. The Good Guvn’r Cooper is trying to use this fight to force expansion on the state and vetoed the latest Republican compromise bill. Stay tuned.

IOWA RATES FINALLY FINALIZED 2 WEEKS INTO FISCAL YEAR– Which is better than last year which went 2 months past the contract start dates. MCO rates got bumped another 8.6%- but that’s all going right back out to providers (facilities, mostly) and Big Pharma (hep c coverage). There is also new funding included for more MCO “oversight.”

FL COUNTIES RAISING ALARM OVER TRUE COSTS OF MEDICAID EXPANSION DREAMS– See, all that “free” Medicaid money comes from somewhere, even at the state level. And in many states, a ton of that state money comes from counties, who must fund it with property taxes. So, one neighbor’s millage is another’s Medicaid. Whether the funding neighbor likes it or not (or even knows it). Well in FL (where they Expansion Lobby incessantly tells everyone they must expand, just like in every other non-expansion state), some small counties are trying to build awareness. It doesn’t hurt that Florida has a law that requires actual economists (which are different from NYT columnists promoting junk science, by the way) to assess the financial impact to Florida’s “fiscally restrained” counties.

MANY STATES TALK ABOUT CONTROLLING OUT OF CONTROL MEDICAID SPENDING DEATH SPIRAL; ALASKA IS ACTUALLY DOING IT- AK Governor Dunleavy is not playing the normal game of “appear hard on Medicaid spending but eventually cave” and just do what the Medicaid lifers (and industry lobbyists) tell you to do. The Good Guvn’r just vetoed $58M in state monies for Medicaid (including jettisoning the adult preventive dental benefit). The immediate, across-the-board provider rate cuts triggered a lawsuit from the Alaska Hospital and Nursing Home Association (the groups who get the lion’s share of the Medicaid biscuit). Yeah, I just replaced pie with biscuit- and you love it. Hold on tight, Guvn’r.

ID SUBMITTED A 1332 WAIVER TO ALLOW MEDICAID EXPANSION MEMBERS TO NOT ACTUALLY HAVE TO BE ON MEDICAID- Idaho is expanding Jan 1, 2020. Right now there are about 18,000 Idahoans on the exchange who will have to drop their commercial policies because they would qualify for Medicaid. The state has asked CMS for permission to instead subsidize their exchange premiums instead of moving them onto Medicaid. Analysts currently expect CMS approval, since it is similar to a request approved for Utah earlier this year.

I SEE WHAT YOU DID THERE (EMPIRE STATE SHENANIGANS MEANT TO COVER UP FAILURE TO CONTROL MEDICAID OVERSPENDING)- This one is delicious. The good Guvn’r Cuomo quietly slid $1.7B in Medicaid spending by delaying a payment 3 days. Why does that matter? Because it was at the very end of a fiscal year, and it allowed the state to look like it was compliant with state law that keeps Medicaid spending increases capped at 3%. If the transaction were made when it was supposed to (and more reflective of actual costs and spending, which is of course more in keeping with both the letter and spirit of the law), then the state’s fiscal failure would be obvious. Its looking like the state is on track to overspend again this fiscal year. Don’t worry, they will just slide the payment again next year!

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker- no fraud follies this week, friends. Just not enough time in the day or space in the column. Let’s all just pretend its not happening this week (makes me feel better, anyway).

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 (pressure wash your driveway, its miraculous!) 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 jiberdi

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2XR8wTL

For optimist readers- http://bit.ly/2XQzwD0

CA MAKING IT EASIER TO TEXT- While it pains me to realize that 1991 is now 28 years ago (1991 is when the law blocking spam texts was passed; its also when this album came out and changed all of music), it does seem like maybe our SMS policy needs a touch up. See, when healthcare companies can’t use the communication method that 50% of Americans say is their primary day to day method, we have a problem. Why can’t an MCO text Clay the Medicaid bennie? Because laws. And stuff. The California health agency is working to remedy that by laying out some basic ground rules to make it easier for MCOs. Summary of the rules: submit a form to the state to text to members, make it free, give them an opt-out option and let us know your game plan re: privacy protections (hint- don’t let Amazon or Facebook access the info so they can market them new products via their discounted Medicaid/EBT Prime accounts).

GARDEN STATE WELCOMES NEW DIRECTOR TO THE HELM- Jennifer Jacobs will be the next New Jersey Medicaid Director by late July. Jennifer- We’re glad you’re here!

INDIANA WORK REQUIREMENT BEGAN LAST MONDAY- By Tuesday morning, there were 17 lawsuits filed, 4 HuffPo articles explaining how Evil this is, 2 protests in the streets and 4 new Democratic Presidential Candidates. Ok that last one was unrelated to the work requirements program beginning. Members subject to the requirements (as in all the of the states trying to roll out this feature, almost all members are exempt) will have to work 20 hours a month in year 1 (which boils down to 5 hours a week, or 1 hour a day, M-F).  So 240 hours of total work to obtain a benefit valued around $6,000 comes out to being paid $25/hour if you have to work for your health insurance.

OREGON MCO AWARDS ARE OUT- CCO 2.0 (Coordinated Care Organizations, for those that missed the first memo 5 years ago about how this was the next great idea that was going to save Medicaid from a financial death-spiral) is now live after the MCO awards were announced this week. All incumbents won except for 1 (Primary Health), with 4 newbies given 1-year contracts as a type of probation.  Congrats to our friends and clients in the winning orgs. Here’s to five more years!

EMPIRE STATE TAKING LTC RESIDENTS BACK OUT OF MANAGED CARE- Under new NY policy, skilled nursing facility residents will be back in fee for service if they are in a facility more than 90 days (assuming the carve-out is approved with the CMS waiver in play). The thinking behind the change is that there’s not a lot of cost management achievable for long term institutional residents (NY thinks they will save $158M savings in the first fiscal year)- so why pay an MCO basically an additional administrative fee. I personally am skeptical that there is no room for efficiencies in nursing facility management, but we shall see.

NEED A JOB IN ILLINOIS? There are 300 new job openings to help deal with the pile of Medicaid applications that are backlogged (more than 100,000 currently, which are older than 45 days – which is non-compliant with federal rules).

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. Not a lot to cover this week, but let’s at least scratch the itch… Vasso Godiali of Bay City, MI got popped for his role in a $60M healthcare fraud (not sure how much was Care vs Caid). Seems he had a penchant (been a while since I used that word) for bogus stent claims. What started out as a Medicaid fraud case got bumped up to include Medicare when the state folks realized they were just the tip of the iceberg. Qaiser Gondal of Watervliet, NY plead out in Albany this week. He was part of the dozen or so thugs using Ti Taxi to steal multiple Medicaid millions. And finally, Nikkitta Chesney of Bridgeport, CT joined her partner in crime (Toshirea Jackson) at the sentencing hearing for their Medicaid fraud. Their crime? They stole Medicaid bennie IDs (about 150 of them) and then used them to steal $3.9M using fake claims for psychotherapy services. The lovely ladies Nikkitta and Toshirea are our winners this week, albeit on a technicality (since we don’t know the Care/Caid loot mix for Mr. Godiali). Congrats, fraudsters! You get a Mostly Medicaid Fraud All-Stars T-Shirt. It comes in orange and also in orange.

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 (if you bag the grass when you cut it, it does really help with weeds after a few years. Every think about how many seeds are in the soil in your yard? Scientific notation is surely required) 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: Chuir an t-Athair am Mac gus an saoghal a shàbhaladh

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

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

HAPPY BIRTHDAY TO YOU- Happy birthday to you. Happy birthday, dear America- Happy birthday to you!

RATES? WE DON’T NEED NO STINKIN’ RATES- On July 1, MCOs in Iowa began another fiscal year without official capitation rates (the same thing happened last year- it was 2 months before rates got locked down then). Last time this happened it didn’t turn out too bad for MCOs, though: They got an 8.4% bump.

CMS FUNDING NEW OPIOID TREATMENT GRANTS- CMS announced new $50M grants available for states to improve substance abuse treatment and recovery efforts. The feds are looking for proposals that would fund 18-month pilots. Applications due August 9^th.

PRAIRIE STATE OWES FEDS LOTS OF DOUGH- Seems Iowa did not collect rebates on about $7M worth of Medicaid drugs. Federal HHS IG sent a letter looking to collect on the $4M federal share of those rebates. HHS has been reviewing state rebate collections, with Illinois being the 36^th state to have its tires kicked. NJ has been asked to pay back $8M.

SOONER STATE DOES, TOO- Oklahoma had some recent success suing Purdue Pharma. By success, I mean they got a settlement of $270M awarded (all related to Purdue’s OxyContin marketing practices, I think). Well someone at CMS saw the news and sent a letter to OK Medicaid making sure they knew the feds were entitled to some of that money. The Good Guvnr Stitt is currently saying no dice, federalis.

NH TWEAKING WORK REQUIREMENTS- Dem state reps have been trying to undo the deal they made to keep expansion going. Looks like a compromise is being struck- the requirements stay, but there are now no penalties for non-compliance.

AK TIGHTENING THE BELT- The Good Guvnr Dunleavy is cutting $444M from the overall state budget, with $50M of it coming from Medicaid. Here is a quote that will strike terror in the heart of Medicaid-industry lifers: “Cost-saving measures can be achieved in the Medicaid program through creativity, program reform, and focusing on fraud.” What the heck does he mean cost savings through creativity? Reform? Focusing on fraud? How dare he?! Has no one told him yet the way Medicaid actually works? Someone talk to this man!

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. Brenda Copeland of Warner Robbins, GA stole near bouts $500k using her counseling business. She was charged this week with filing false claims (and I think it may have been to an MCO, but not sure. If you are, please weigh in). Move on up and over to Pulaski County, Arkansas where we meet Charline Brandon. She has to pay back $289k to AR Medicaid for tricking patients into thinking they were dying so they would sign up for hospice (that’s a particularly special kind of cruel). One victim spent 3 years in hospice. For another entry in the despicable department, head back east to Greensboro, NC. Here we meet the good people at United Care Youth Services. According to allegations made by patients, this outfit is requiring people to stay hooked on drugs so they can stay in their housing program. Plaintiffs say they were provided free or reduced housing as long as they did not have 3 clean, consecutive drug tests. The organization also provided classes and substance abuse treatment, then billed it to Medicaid. As of the time of writing all allegations were being denied but state investigators are looking into this and other similar schemes. Ann Eldridge and Angela Keith of Sumter, SC are wrapping up their court adventure over their pilfering of $13M from Medicaid. How did they do it, you ask? Using their organization (Early Autism Project) to bill false claims over a 9-year period. The two ladies ended up getting 6 months in prison… Ok enough southern-fried fraud- lets move this party up North. Crispin Abarientos of Middletown, CT plead guilty to getting $894k worth of Remicade (an injectable used for rheumatoid arthritis) using false claims to Medicaid. He then turned around and used that Remicade on commercial or Medicare members and got paid by those payers. So get some “free” Remicade (paid for by Medicaid-funding citizens), then sell it to Medicare and commercial plans. Total taxpayer tab (grin and bear it, you suckers!) for this paragraph: $14.7M. Our illustrious ladies from South Carolina (Mrs Eldridge and Mrs Keith), 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 (stare long and hard at those almost-ready tomatoes) and keep running the race (you know who you are).

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

Trystero: Chúa Cha đã sai Con đến cứu thế gian.

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

For optimist readers- http://bit.ly/2VPQuk2

KNOW WHY YOU GET TO GRILL BURGERS ON MONDAY? Because brave soldiers died protecting you from threats home and abroad. Take a moment to learn about a few heroes who died recently- http://apps.washingtonpost.com/national/fallen/

OKIES DARING TO FOLLOW REGULATIONS AND CHECK ELIGIBILITY BY MAIL- In order to make sure the member rolls are accurate (sort of an important thing, especially in managed care states), CMS requires states to, you know, verify members exist. Part of that involves attempting to contact them. Attempting to contact them by mail is how CMS suggests to do it. Oh yeah- it also proves you live in the state (a term called “residency”). In the never-ending story of making it impossible to actually be a good steward with hundreds of billions of dollars, #Resisters in OK are ticked about a proposed rule to take bennies off rolls if the letters they send are returned undeliverable. Next year all it will take to get a Medicaid card will be to wish upon a unicorn’s left hoof and “poof” – you’re in!

CMS JOINS SPREAD PRICING FRACAS- Last week the Big House released guidance to states and plans about how to view spread pricing and MLR. The gist – it does impact MLR and any vig that an MCO paid to a PBM via spread pricing does NOT get to count as medical costs. Go figure.

LEARNING MORE ABOUT NC SDOH PILOTS- Key things you need to know: $650M will go to pilot programs for 50,000 bennies ($13k/each for Roundup Readers playing at home). Programs will address housing, transportation, food, and interpersonal violence. MCOs will manage the budgets for each benny in the pilots. RFPs for the Lead Pilot Entities (LPEs- the network builders) expected round about Thanksgiving.

BYE, MR. TRAYLOR- Chris Traylor, current head of the CMS Medicaid and CHIP services unit, will be stepping down on May 31. Calder Lynch (who did our state spotlight show a few years back) will be acting director.

BUT, YOU SEE, IT DOES FURTHER THE GOALS OF THE PROGRAM- When we’re not blowing money on people who don’t care enough to comply with paperwork, there’s more money to help the sick people on Medicaid waiting lists. At least that’s the argument being made in the Trump Team’s appeal of the work requirements lawsuits. Keep in mind the argument in the suit that slowed work requirements was that they did not further the goals of the Medicaid program. By showing how the new requirements do further the goals for the people who need it most, Team CMS has accomplished what in policy debate is known as a “Turn.”  Or maybe they’re obstructing some sort of Russian dossier under the emoluments clause of the 32^nd amendment or something. Who knows? Rachel Maddow, that’s who.

ANOTHER OH MCO DROPS CVS- Buckeye Health dropped the drug giant this week. Caresource led the way a few weeks back.

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THE MEDICAID BLACK BOOK IS HERE- Want to know what’s on the mind of MCO CEOs? Want to see our in-depth reviews of vendors? Current issue is out. You can check it out here – http://www.mostlymedicaid.com/?product=medicaidblackbook

Companies reviewed in current issue:

1. Apixio
2. CareCentrix
3. Digital Harbor
4. HealthCrowd
5. InComm
6. Lucina Health
7. Medical Advantage Group
8. Moms Meals
9. NowPow

• Vheda Health

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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. Sort of a slow fraud week, so your chances of winning are higher. Hellen Kiago, of Sturbridge, MAH was convicted of stealing $2.5M from MA Medicaid. Her crime? She used her home health agency to bill for unnecessary services and falsified documents. Fun fact- once the coppers searched her office, she wired $1.5M to Kenya. Alejandro and Alexander Jiminez-Incera of Las Vegas were sentenced for stealing $3.7M from Care and Caid. They got caught because of a cash-for-opioids operation they were running, then investigators caught onto a bigger fraud where they were billing for patients they never saw.  Margaret Williams of Anchorage, AK was sentenced this week. In addition to getting one of her nursing home staff killed by having them work entirely alone amongst 5 residents with violent records, and not reporting the death within 8 hours, Maggie stole $1M from Medicaid by billing for services not provided. The Lifetime Movie is due out next week. Mrs Kiago – you win this week’s award for quick thinking in times of pressure. Taxpayers – shut up and smile while you watch your money go down the drain.

Need even more Medicaid fraud stories? – You can get your fix in the FWA Curator archives.

Want to read the articles summarized here, highlighted for your reading pleasure? Check out the News Curator archives.

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 (water and weed, water and weed) 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: Chúa Cha đã sai Chúa Con đến cứu thế gian.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2VnKiQ8

For optimist readers- http://bit.ly/2Vm4O3f

(Special Mother’s Day song selections)

YOU WILL ACCEPT MEDICAID WHETHER YOU LIKE IT OR NOT- Clark County (NV) passed an ordinance this week that requires any new ERs to take Medicaid (and Medicare). Magically, existing ERs / hospitals don’t have to comply.

HUMANA TO CENTENE: “IF THAT WELLCARE THING DOES’T WORK OUT, TAKE A CHANCE ON ME”- Hedge funds with important stakes in Centene have voiced second thoughts about the recently announced WellCare deal. Smelling opportunity, Humana has batted its doe-eyes at Centene. Centene shares up; WellCare shares down. More to come.

OK WE’RE GONNA START CHECKING INCOME FOR REALS, YALL- Louisiana reps are moving forward with a bill that will – wait for it- connect Medicaid eligibility systems to federal tax data to verify income eligibility. Where are all the kudos from the people telling me interoperable big data is the answer to everything? Can I get an Amen? The space-age tech comes on the heels of highly publicized news of LA having to kick 30k members off the rolls for earning too much money (some of them six figures). #Resist!

GROUNDHOG DAY: NORIDIAN WINS IOWA MMIS CONTRACT, AGAIN- Yet another snub to the whole modular / let’s shake things up and get some fresh blood in the MMIS world movement. Noridian (congrats, btw) won the Iowa MMIS contract again. It has held it since 2004.

FASTER WAIVERS- CMS approved waivers in 16% less time in 2018 compared to 2016. New reports coming out of Madame Verma’s office show that long overdue bureaucratic reforms are working. 78% of waivers are now approved within the first 90-day review period. And the backlog of pending state plan amendments is now down 80%.

LOOKING LIKE LIMITED EXPANSION WILL PAY AT SAME RATE AS FULL ACA EXPANSION, SUCKERS! –  I have sat through nearly a decade of obnoxious taunts from blue states to red states about being fools for not taking the awesome federal gravy train money deal for expansion. Seems like hold outs may have the last laugh- not only will they possibly get the same FMAP (90%) under a more responsible, limited expansion on their own terms – they also got to sit out of the spending orgy that got all those expansion states even more addicted to the federal teat from 2010 to 2016. CMS is saying its open to paying 90% of costs of “conservative” expansion plans like the ones being asked for in GA (that go up to 100% FPL vs 133/8). The Peach State plans to submit its waiver to CMS by the end of the year.

VOLUNTEER STATE MOVES FORWARD WITH BLOCK GRANTS; PEARLS CLUTCHED- State reps passed a bill that gets the governor to submit an 1115 to CMS to convert TennCare into a fixed-payment program (vs the open-ended, spend forever, drive-it-like-you-stole-it normal model). Similar to what Utah did in February. Other sources report that CMS is expecting more states to request a block-grant conversion, and the agency is drafting guidance on how to make the ask.

WE, LIKE, TOTALLY VOTED FOR THE SIMPLE EXPANSION, MAN! GIVE US THE SIMPLE ONE NOT THIS COMPLEX MEDICAID STUFF- You can’t blame voters in Nebraska for thinking the work in expanding Medicaid was done when they filled in their ballot bubble. Everything is oversimplified for the electorate, and healthcare is no exception. Problem is somebody must pay for what they thought they were ordering off the taxpayer menu. In their minds they were getting the Porterhouse for 100,000 of their newest Medicaid card-carrying friends. In reality there’s no budget for Porterhouse, so voters may end up ordering off the kids menu. What do you do when you don’t get what you want in modern America? Sue! And that’s of course where this is going… Resisters have already fired up the outrage machine and are threatening litigation.

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THE MEDICAID BLACK BOOK IS HERE- Want to know what’s on the mind of MCO CEOs? Want to see our in-depth reviews of vendors? Current issue is out. You can check it out here – http://www.mostlymedicaid.com/?product=medicaidblackbook

COME HANG OUT IN BALTO IN MAY– I’ll be speaking and generally gallivanting at the Medicaid Managed Care Congress May 20-22^nd in Baltimore. Would love to see you there. Check out the event here- http://bit.ly/2ZsRcqd

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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 (record scratch sound)- not so fast this week dear readers. I wrote too much above and need to land this plane.

Need even more Medicaid fraud stories? – You can get your fix in the FWA Curator archives.

Want to read the articles summarized here, highlighted for your reading pleasure? Check out the News Curator archives.

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 (thin things that are sprouting to the proper spacing- there’s info on that seed packet if you didn’t throw it away) 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: piyāṇan vahansē lōkayaṭa gaḷavannaṭa putrayā evū sēka