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Clay’s Weekly Medicaid RoundUp: Week of February 11th, 2019

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2X0xroM

For optimist readers- http://bit.ly/2X0qqEz

NEW ONLINE TRAINING COURSE IS OUT– Want to understand the opioid crisis? Our newest online course will help. Check it out here- http://bit.ly/2WEL3G4

IDAHO DECIDES TO MEASURE IMPACT OF EXPANSION- Medicaid expansion is getting its very own budget item so it can be tracked precisely. I know about 30 states who wished they would have thought of this.

ALASKA BACKLOG OF APPLICATIONS GOING DOWN BUT STILL A PROBLEM- The Frontier State is struggling to scale its Medicaid program after expansion nearly doubled its rolls.

 MEDICAID ROLLS DECREASING IN SOME STATES; LEFTIES FORGET THE “BUT MEDICAID IS COUNTERCYCLICAL TO THE ECONOMY” LINE- To admit the economy is improving would admit The Duly Elected President of the United States of America (DEPOTUS) just might be helping rescue us from the disastrous economy he inherited. Such an admission is impossible for most in our Medicaid world. Other theories: re-enrollment apps are too many pages long (TN has 47 pages to fill out to get back on the rolls) or bennies re-applying have to wait on the phone lines too long (MO). Overall, Medicaid enrollment declined about 1.5% nationally last year. Which really isn’t that much when you realize it basically doubled in an 8-year period under ACA. So, class- Medicaid grew 100% in 8 years, then it took a 1.5% step back in the last year. (At this rate it would be 2120 before we got back to pre-ACA bennie levels). Let’s all FREAK OUT!!!! ORANGE MAN BAD! I’ll leave you with this quote from a TN Medicaid official – ““Tennessee is experiencing a state economy that continues to increase at what appears to be near-historic rates.”

 MICHIGAN WORK REQUIREMENTS BATTLE RAGES ON- The Good Guvn’r (the new one- Whitmer) is looking to undo the work requirements plans already approved by CMS. She has a new report with bigger numbers on how many will lose coverage if they don’t comply with the requirements. Pro tip for those wanting to undo work requirements already approved by elected (that word is put there to remind you that about 50% of voters disagree with you) officials: looks like you just need to know the right consulting firm to get the numbers you need to justify the reversal.

 

VOLUNTEER STATE STEPS FORWARD FOR BLOCK GRANTS- TN state reps filed 2 bills this week (1 in the house, 1 in the senate) to require the Medicaid agency to request a waiver from CMS to convert to a block grant program. 1st shots fired. For history buffs wanting to chase a rabbit trail right this moment instead of doing whatever you are supposed to be doing at work, read the wiki page about an American hero involved in the first shots fired during the American Revolution- Crispus Attucks. For all you whippersnappers drinking the green kool-aid, the American Revolution was how this unique, wonderful country got started and began the beautiful, unique, one-of-a-kind story that is America. Thank you, Crispus, for your role in making this place awesome.

 

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. Manuel Barit of WV plead guilty to stealing $200k. His crime? Submitting claims for treating bennies when he was actually out of the country. The scam went on for six years. Ryan Sheridan of Austintown Township (Ohio) was charged with stealing $31M with bogus substance abuse treatment claims (DBA “Braking Point Recovery Center”). He and his buds operated recovery centers all over town. Lillian Richardson and Bridgett Burrel of Minnesota got convicted this week of stealing $7.7M in Medicaid bucks using five (count em’, five!) home care agencies they set up under the names of different family members. They submitted lots of bogus claims for helping disabled Medicaid members with daily tasks. Fun Fact- Richardson was convicted on a different Medicaid fraud in 2012 but pinky-swore to not do it again. Guess pinky swears are not what they used to be in 4th grade.  Mr. Sheridan – you win. $31M is a decent chunk of change, even for Medicaid fraud.

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 (or stay inside and order seeds – its that time again) 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: Rama dikirim Putra ka ngahemat dunya.

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Medicaid Who’s Who Interview: Deborah Watkins

Deborah Watkins is Founder and Chief Disruption Officer of Care Bridge International.
Check out her LinkedIn profile HERE.
Which segment of the industry are you currently involved?

Health Data Analytics, specifically involving bodily injury claims. About 20% of workers comp and auto injury claimants have serious enough injuries to qualify for Social Security Disability Benefits, followed by Medicare benefits. A percentage of those individuals eventually receive Medicaid benefits due to the severity of their injuries and income constraints. There is a real opportunity to ensure these individuals receive quality care to promote their independence, while preserving and maximizing these State & Federal funding resources to improve outcomes, but also to ensure the fiscally responsible use of these funds.

How many years have you been in the Medicaid industry?

On the insurance side, over 18 years, but have been in the healthcare space my entire career.

What is your focus/passion? (Industry related or not)

Dual Eligibles, individuals who receive both Medicare and Medicaid benefits, as these individuals are the most compromised and most vulnerable in our healthcare system. This small subgroup consumes the largest portion of our healthcare dollars having a big impact on our healthcare GDP. Being a small part of the solution in the healthcare delivery and payer systems, is my passion.

What is the top item on your “bucket list?”

To snorkel or scuba dive with humpback whales. I have had an interest in whales since childhood and want to get as close as safely possible.

What do you enjoy doing most with your personal time?

I’m an outdoor girl and enjoy out-of-door activities, particularly trekking in scenic places around the world and downhill skiing.

Who is your favorite historical figure and why?

Abraham Lincoln. He was our President during a very polarizing time in our country’s history during the Civil War and is one of our most respected Presidents. In addition, he experienced tragedy in his own personal life including the loss of his mother at age 9 and the death of a son that led to his wife’s mental health issues, so he was a man familiar with tragedy, yet very resilient. I admire that, because I have a daughter who had an acute head injury at age 9 and suffers with chronic, intractable epilepsy. I understand at a personal level the pain of loss and the challenges caregivers face in navigating a fragmented delivery system and the need for a Medicaid safety net. The story of Honest Abe gives me hope that we can successfully solve our healthcare crisis and reunite.

What is your favorite junk food?

Salt Water Taffy, I love its sticky sweet taste that melts in your mouth; it reminds me of the Boardwalk in Ocean City, MD, not far from where I grew up.

Of what accomplishment are you most proud?

Being an advocate for my daughter, successfully navigating both the healthcare and education systems and adult community resources to help her live as healthy and full a life as possible, to achieve her highest potential despite her afflictions.

For what one thing do you wish you could get a mulligan?

Well, there are many! But for public consumption, I would like to get back the hours of vacation that I worked instead of enjoying that vacation. Time off, disconnecting from the laptop and the stresses of work, is important to maintaining balance and well-being.  Vacation is important for restoration. I encourage my own employees to use their time off for that purpose, and stop checking email!

What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?

I think the most important issues involve, not just figuring out how or how much to fund Medicaid, but how best to manage these funds. Throwing money at a program is not the solution, understanding how best to deliver care to Medicaid beneficiaries in the most cost-effective way to obtain the best possible health outcomes is a complex task, but this is what needs to be done. The use of Data analytics offers a powerful means to learning and understanding and seeing the problems and solutions more clearly. Engaging and gathering Data from all stakeholders including payers, beneficiaries, community leaders, caregivers, providers, facilities, pharmacies, and more to create a better understanding of where the opportunities are to build a more efficient ecosystem is what I believe should be the focus in the next six months. It is the hard, but important work that needs to be done to strip out biases’ and false assumptions that are holding us back from better serving the Medicaid population.  

 

Know someone in the space who’s doing great work and is an all around interesting person?
Send a note to clay@mostlymedicaid.com to nominate them for the next round of Medicaid Industry Who’s Who Interviews.

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Medicaid Who’s Who Interview: Benjy Green

Benjy Green is Vice President, Business Development of Magellan Health.

Check out his LinkedIn profile HERE.

1. Which segment of the industry are you currently involved?

I have been at Magellan for about 18 months now, and loving it. I’m currently working on various Medicaid RFPs, ranging from LTSS to TANF populations in different states.

2. How many years have you been in the Medicaid industry?

I have over ~20 years experience in Medicaid and Government programs, with areas of focus including provider, state, federal and managed care organizations.

3. What is your focus/passion? (Industry related or not)

My number one focus is my wonderful family, wife Amanda and three teenagers (Ben, Zach and Kate). Outside of that is my passion to help the underserved and vulnerable populations.

I stumbled into this career path by starting in the business office of a small provider. I quickly felt the desire to do more for this population and transitioned into state employment at a Texas Medicaid Agency. I can’t imagine doing anything else, this is what drives me.

4. What is the top item on your “bucket list?”

I’m not sure I have one top item, but we love to travel. We are looking at options in Europe in the near future and plan to visit Scotland for my 50th in a few years to play St. Andrews, the home of golf.

5. What do you enjoy doing most with your personal time?

Spending time with my family, friends, including my four legged friends. My family is heavily involved with the DFW Labrador Retriever Rescue Club, so in addition to our Jack Russel (Scooter) two labs (Bria and Kenner), we often have a foster dog running around as well.  I also enjoy as much golf as I can get in.

6. Who is your favorite historical figure and why?

I’m not sure I could pick just one. But if hard pressed, I’d go with any of our country’s founders. They were a complimentary mix of writers, philosophers, and politicians who not only led the revolution, but had the foresight to put the structure of this great country in place hundreds of years ago.

7. What is your favorite junk food?

I love chocolate and anything covered in chocolate.

8. Of what accomplishment are you most proud?

I am a first generation college graduate with a Master’s degree. Even though my parents didn’t have the means or opportunity to attend college, they understood the importance of higher education, and pushed my brother and me to graduate from college. As a parent myself, I share the same philosophy, and will do everything possible for my children to have the same opportunities that I did.

9. For what one thing do you wish you could get a mulligan?

Running for my neighborhood HOA board! (This is my sense of humor coming through, if you don’t know me personally).

In all seriousness, I’m not a fan of mulligans on the course and therefore wouldn’t take one in life either. I feel the decisions, good or bad, have lead me to where I am today, both professionally and personally. I’m living my best life today, and am very thankful for the experiences that have gotten me to this place.

10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?

Approach to “managing” members – historically the focus has been on managing the physical health of Medicaid populations. As organizations dig deeper into the data, it’s becoming apparent to be successful we must focus on the behavioral diagnoses (where applicable), then the physical. Here at Magellan, with our more than 40 years of behavioral experience, we are evolving our approach which is making a difference, especially with the vulnerable populations we are entrusted to serve. We are also using technology to our advantage to not only reach the members but gathering data from all streams (physical, behavioral and pharmacy) to better understand how we can make a difference.

SDoH – as organizations improve the importance of the interdependencies in Medicaid populations, the relevance of the Social Determinates of Health is a driver to be successful to improve outcomes within the Medicaid populations.

Opioids – this has a tremendous financial impact on all of healthcare, not just Medicaid. Everyone (payers, pharma and providers) must meet on common ground to address the epidemic and find a solution.

 

Know someone in the space who’s doing great work and is an all around interesting person?
Send a note to clay@mostlymedicaid.com to nominate them for the next round of Medicaid Industry Who’s Who Interviews.

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Medicaid Who’s Who Interview: Bill Henderson

Bill Henderson is the Sr. VP Business Development at Liberty Dental Plan. 

Check out his LinkedIn profile HERE.

1. Which segment of the industry are you currently involved?

LIBERTY Dental Plan is a leader in the Medicaid /Medicare industry. A leading National Provider of Dental Managed Care Services since 2001. Providing quality, innovative and affordable dental benefits with the utmost attention to member satisfaction

2. How many years have you been in the Medicaid industry?

I started back in 1993 partnering with MCO’s within TennCare for vision care. 

3. What is your focus/passion? (Industry related or not)

Increase access to dental services and oral health education to all members, focusing on co-location and prevention. Providing more education to underserved population so they can have a clearer picture of what great oral health is and how it can assist them in their whole-body health.

4. What is the top item on your “bucket list?”

To establish & set up pop-up housing for the social determents and provide fresh vegetables for them, and a clinic to assist them within the housing unit.

5. What do you enjoy doing most with your personal time?

I travel every week for work but I still like to travel to areas I do not get to see, love to experience local food and culture.

6. Who is your favorite historical figure and why?

Lincoln, to me he put everything ahead of himself & his career. He was concerned about the country and the rights of the people and wanted to make sure he resolved the issues we were having at the time.

7. What is your favorite junk food?

Street hot-dogs, love them in NY

8. Of what accomplishment are you most proud?

Being able to assist LIBERTY to grow across the country, we’ve built a great team, and winning culture that all the team care about the people we get to serve and the communities we operate in.

9. For what one thing do you wish you could get a mulligan?

Not always being home to see the kids growing up

10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?

A. The cost of end of life

B. States need to flexibility working with MCO’s to manage the programs set forth and develop strong relationships with plans/provider and communities

C. Get a better handle on Social Determents and the cost of care for this populations

Know someone in the space who’s doing great work and is an all around interesting person?
Send a note to clay@mostlymedicaid.com to nominate them for the next round of Medicaid Industry Who’s Who Interviews.

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Medicaid Who’s Who Interview: Amanda Ratliff

Amanda Ratliff is the CEO of ACR Consulting Services & COO of Paragon Technology Partners.

Check out her LinkedIn profile HERE.

1. Which segment of the industry are you currently involved?

Network Development for Payers, Managed Care Consulting, Credentialing, FQHC/Radiology and Vision Billing, Directory maintenance and IT Solutions (BigData, encryption, PDM).

2. How many years have you been in the Medicaid industry?

I have the worst baby face (I literally look 12), but over eighteen years.

I started at Aetna in the member services call center and worked my way up to CEO. I never turned work down – I always did the dirty stuff no one wanted to and kept learning. When it was hard and there was no structure or policy, I kept at it until we had clear sight. Medicaid is a tough industry and doesn’t have a lot of funding. It takes dedicated teams with a true passion and vision. I have been lucky enough to work with some of the greatest teams.

I always wanted to do the best I could with minimal spend. We helped to orchestrate a consolidation of 3 different systems while at an MCO. They were paying 3 different teams and 3 separate software programs. It didn’t make sense. All data should be in one source.

3. What is your focus/passion? (Industry related or not)

My main passion is Contracting and Provider Data Maintenance. I love to contract Providers/Groups/Hospitals and make sure the data collected in the process is correct, clean, valid and complete. Incorrect directories and fat finger typos drive me absolutely INSANE. Also, automation – if there is a way to do something faster – I am visioning how to make it happen.

4. What is the top item on your “bucket list?”

Professionally – I would like to see Provider Data Management (PDM) solution solved so Payers could manage their data, and not be fined for incorrect information.

Personally –  I would love to be able to go to Italy with my husband – his grandfather came over off the boat from Naples and he wants to visit his history (and eat a bunch of pizza and pasta!)

5. What do you enjoy doing most with your personal time?

Watching non stop episodes of Heart of Dixie on Netflix, women’s bible study, helping others, Horseback riding, and quality time with my 16 yr old son and 10 yr old daughter (if they like me that day).

6. Who is your favorite historical figure and why?

Martin Luther King Jr. – he rose above all odds, stuck to his faith and did what was RIGHT in every scenario. You don’t see people STAND UP like that with deep concern to risk everything. He didn’t give up and he had every right to. His battle is unlike anything I’ve ever experienced and I admire his unwavering passion. That man changed the complete path of our nation, amazing.

7. What is your favorite junk food?

Fritos and Nacho cheeeeeeese

8. Of what accomplishment are you most proud?

Stepping out in faith and opening a business with employees (I never thought of myself as a boss – it’s still weird for me to think about).

My employees are simply the best and often outwit me. Steve Jobs said – “you should hire people who are smarter than you”, and I am thankful that my team is well equipped and have such a deep knowledge of the space.

I just continue to let God lead – he pushed me off the cliff and I haven’t fallen yet! When in doubt, take the risk and TRUST HIM.

9. For what one thing do you wish you could get a mulligan?

Not finding Christ sooner……… and picking on my older brother and him always winning!

He stuck me on top of a 6 foot bookshelf, turned the lights off and left Opera music playing so loudly he couldn’t hear my screaming and crying.

Then, one time I asked him what to do about my skinned knee – and he told me to put lemon juice on it…and I DID! I wish I was the oldest and not youngest.

(Yes, I am whining about it after 30 years).

10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?

A. BigData, lots of data and data analytics. Smaller MCO’s and new MA plans coming in don’t have access to well adopted systems/policies/etc. They lose a lot of revenue in start up or initial bids/risk to secure agreements.

B. Technology – who is coming out with what and why? Is there a list of all this awesomeness?

C. Patient Care and Access – we need more doctors and nurses to care for (and accept) patients. Lots of them are lost in the shuffle, especially the homeless.

Know someone in the space who’s doing great work and is an all around interesting person?
Send a note to clay@mostlymedicaid.com to nominate them for the next round of Medicaid Industry Who’s Who Interviews.
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Clay’s Weekly Medicaid RoundUp: Week of January 14th, 2019

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

For optimist readers- http://bit.ly/2W235C3

ABOUT THAT WHOLE MEDICAID TRANSFORMATION IN NY THING. YEAH, LET’S STOP DOING THAT- After years of major overhaul efforts to transform its Medicaid program, Cuomo just pressed pause on the key device real driving change. For 8 years, NY has capped Medicaid spending to be within a 10-year rolling average of medical inflation. In this next budget, the Good Guvn’r decided to give Big Med (primarly hospitals) a pass and allow Medicaid spending to exceed the cap (3.1% is the cap; Cuomo is authorizing 3.6%). Why, you ask? As a pre-emptive strike (in his view) to shore up against federal changes coming to Medicaid. What federal changes? Reductions in DSH that were started when ACA passed (in 2010), but Big Med has been able to get delayed year after year.  Lefties, rejoice (and don’t forget to vote for him when he runs for Pres in 2020). Righties, observe yet another tax and spend Dem refusing to reform their ways (cuz, you know, they’re the good guys and your’e evil if you doubt that). Total Medicaid budget now that NY Medicaid is on a cheat-day? $19.6B (which is roughly the GDP of Botswana, and more than the GDP of 118 countries. For freakin’ Medicaid in NY, people).

HOW WAS YOUR EXPERIENCE? MA TO POLL PATIENTS- Medicaid members in The Old Colony State will be asked to rate providers and plans for the first time. Results will be made public in 2020. From what I can tell this is basically a CAHPs-type survey. Results will also likely be used for value-based care payments.

SHAKEUP IN ARKANSAS NEMT- For readers keeping tabs on the Medicaid transportation scene: Southeastrans is picking up more regions as MTM will exit. Handover starts Feb 1.

JUST WHY ARE HOSPITALS IN VIRIGINIA SO EAGER TO BE TAXED? Why do hospitals exist? To help people AND to make money. When asked why they exist, what is the answer? “To help people.” They conveniently leave out that second part. When you put it back in, it makes a little more sense why VA hospitals are eagerly paying a “tax” to help fund the recent explosion (expansion) in Medicaid spending. State reps are getting their first taste of the “surprise” cost over-runs in the expansion they approved last year. This week new adjustments to expansion costs show at least $85M more than what they were told when they voted “yes”. Hospitals, those noble creatures they are, are running full press coverage highlighting how they are so, so happy to pay a tax to help fund expansion. Long time readers remember that Medicaid provider taxes are often a total sham described thusly: we pass the hat to hospitals, who all chip in money. We then beam up the hat to planet CMS, who puts in 6x more money (or 7x or whatever your fmap is), and then sends it back down. The state gets more cash, and so do the hospitals.

PALMETTO STATE JOINS RANKS OF WORK REQUIREMENTS REFORMERS- Looks like another 1115 app will be hitting the halls of 7500 Security Blvd in Balto soon (where planet CMS is). South Carolina is doing town halls on a work requirement proposal as of this week.

IMPLEMENTING BALLOTED (IS THAT A WORD?) EXPANSION PROVING TO BE HARDER THAN CHECKING A BOX ON VOTER CARD- Utah lawmakers are trying to figure out how to pay for the expansion approved by voters in November. There are 2 issues in play: 1) how to keep the limited expansion already in place going while applying for CMS to approve full / “standard” expansion we’ve all come to know and love; and 2) how to come up with numbers during the current budget cycle that at least try to pretend there’s a way the state can pay for it. A sales tax increase is projected to come up about $45M short in the next few years.

HOSPITALS AFRAID SETTING LIMITS ON MEDICAID SPENDING COULD HURT THEIR REVENUES- See earlier entry above about why hospitals exist. As CMS suggests states may find approvals for block grant waiver apps if they only ask, hospitals are going nuts in the press. Sky is falling, cutting spending will kill everyone- you know the dril by now. There are increasingly insightful quotes coming from Verma on this. Here’s a good lil’ nugget: “We also believe that only when states are held accountable to a defined budget can the federal government finally end our practice of micromanaging every administrative process.“ Hear, here!

IN A RELATED NOTE, GA WANTS MORE FREEDOM FROM FEDERALI MICROMANAGING FOR ITS CITIZENS’ HEALTHCARE NEEDS- The Good Guvn’r Kemp (who recently barely beat romance novelist Stacy Abrams) announced a $1M project to explore a waiver with CMS that would give the state more flexibility with its use of federal Medicaid dollars. No other details than that. You get to fill in the blanks (most fill them in with block grants based on early analysis). In a somewhat related news item, GA teachers will be getting a $3k raise this year.

PASSPORT STRUGGLING WITH NEW NORMAL IN KY- For those of you watching this MCO market, Passport has been unscuccessful in getting the state to budge on recent cap rate cuts that hit Passport particularly hard. Short version – state changed up regions and rates in a way that Passport got hammered. And Passport’s whole business is Medicaid. More to come.

CANARY IN COAL MINE IN AR? We all like to think we are special and unique. Medicaid programs are no different (see what I did there?). Arkansas cooked up yet another version of the “here’s how we’ll transition legacy behavioral health providers to a capitated rate” idea a few years back. (It’s an acronym that spells PASSE; did no one look that up in French?) Like most of these inititaives, year 1 starts out all nice and you get basically extra cash to play along and maybe do a little more case management than before. In year 2 you are expected to manage medical services, pay claims, etc (depending on the state). Well, ForeverCare sees the writing on the wall (or is chickening out if you listen to state officials) and is dropping out. They say they will come back in if the Phase II implementation date is moved to July 1. It has already slid from Jan 1 to March 1.

 

READY FOR MEDICAID INNOVATIONS 2019- I will be there again this year (my 9th time), chairing one of the very best Medicaid events you can go to. Also, its sunny Florida in February (I’m looking at you, Michigan). If you decide to go, let me know and we can meet up. Check it out here – https://www.medicaidinnovations.com/

 

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- not so fast fraud junkies. No where near enough space this week. You can get your fix in the FWA Curator archives though.

Want all the highlighted news items from this week? Check it out here-Medicaid News Curator Volume 5

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 (buy or chop some firewood) 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: Baba alimtuma Mwana kuokoa ulimwengu.

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Medicaid Who’s Who Interview: Johnny Wilkinson

Johhny Wilkinson is CEO of Five Star Home Health Care.  Check out his LinkedIn profile HERE.

1. Which segment of the industry are you currently involved?

We are a full service home health agency, providing both personal care and skilled care to the Washington DC suburbs of Northern Virginia. We try to be the easiest for hospitals and Skilled Nursing Facilities to work with by being a one-stop-shop and being an in-network provider for every payer in the markets we serve.

2. How many years have you been in the Medicaid industry?

I started as a private duty personal care agency in 2006. We were very successful in private duty and our referral partners kept asking us to expand into Medicaid Waiver personal care services, which we completed in 2009. In 2012 we completed our vision of becoming a full service agency by providing Medicaid personal care and Medicaid/Medicare skilled services with a “whole-person” approach to care.

3. What is your focus/passion? (Industry related or not)

My personal passion and business focus are intertwined and optimistically big in scope…I believe we can have a world without Skilled Nursing Facilities or Assisted Living facilities. Seniors want to age in place – near family, friends and their pets. I firmly believe that it’s possible, even with memory care, but it requires a reimagined approach to senior care execution from providers, payment models that support a new approach to facility-less care delivery and technology/data standards the connects everything together. We have a LONG way to achieve my vision, but I’m in this for the long haul. 

4. What is the top item on your “bucket list?”

Traveling outside of North America has always been at the top. I would love to see Europe, Australia and South America. 

5. What do you enjoy doing most with your personal time?

I truly enjoy working on building my business and using time away from work to network with other business leaders and have quiet time to just think. I’m an entrepreneur at heart and for people like me that are lucky enough to do exactly what you want to do, there is no distinction between personal time and work time. It’s all living life to the fullest doing what you enjoy.

6. Who is your favorite historical figure and why?

Ted Turner inspired me to be an entrepreneur. He completely reimagined how news could be delivered by creating CNN. He was laughed at because of the monumental challenges in front of him to build CNN. It’s hard at the beginning of such a massive change in how people have done certain things for decades, and it’s always hard being first at anything big, but true entrepreneurs never give up. The vision pulls them and they cannot let go. I feel the same way about reimagining senior care without facilities.

7. What is your favorite junk food?

The strawberry shortcake at Cheesecake Factory is the best thing on the planet. There is no comparison. 

8. Of what accomplishment are you most proud?

I’m immensely proud of following in my father’s footsteps of building my own business like he did. Although we are in different industries, there is no comparison to seeing your success (and failures along the way) that go into building something from scratch. The accomplishments enabled by running my own business are the ability to hire, empower and develop great leaders. This business is comprised of the hundreds of people who work within it and share my vision. Nothing is more gratifying to me than seeing my team grow and succeed in building their own careers.

9. For what one thing do you wish you could get a mulligan?

In an industry undergoing as much change as healthcare and Medicaid programs, it’s hard to pick just one do-over. But I would have to say the leading do-over would be investing in HR earlier on in the rapid growth of the business. I underestimated the value of employee relations, defining long term career paths for people, training/development and the value HR talent brings in helping you hire for your weaknesses.

10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?

Medicaid has fully transitioned to managed care in Virginia. I firmly believe this is the right move for patients, providers and gives the best value to taxpayers. The per-month, per-member capitated payment model of how the managed care companies are paid, coupled with performance benchmarking required by the state, forces these companies to think creatively about how to deliver better care outcomes, with good patient satisfaction and at a lower cost. Although managed care doesn’t yet fully understand the potential of home care and home health to achieve those goals, I’m bullish on the potential to help them navigate it, realize mutual success and grow my business to new heights in the process. I also see significant potential to infuse physician house calls into my one-stop-shop business model and have a triple win for integrated senior care delivery: Preventative care, primary care and post-acute care.

—————————–

Know someone in the space who’s doing great work and is an all around interesting person?
Send a note to clay@mostlymedicaid.com to nominate them for the next round of Medicaid Industry Who’s Who Interviews.
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Medicaid Who’s Who Interview: Jim McInnis

Jim McInnis is Experienced Chief Executive, CAO, CFO, VP, and Builder of Mission Driven Companies & Relationships. Check out his LinkedIn profile HERE.

1.     Which segment of the industry are you currently involved?

I work with states and MCOs to manage long term care and support services and a variety of waiver programs.

2.     How many years have you been in the Medicaid industry?

Over 20 years, including my consulting and operations leadership roles.  Given how fast things move, the time feels a lot shorter.  It’s terrific!

3.     What is your focus/passion? (Industry related or not)

Having influence and impact in the community.  I often dabble in town politics.  I also like to see people I’ve recruited get promoted and make an impact.

4.     What is the top item on your “bucket list?”

Playing for the Boston Bruins, but that time has well past.  I’d like to do a tour of baseball stadiums with my sons and convince my wife and daughter to attend a couple games too.

5.     What do you enjoy doing most with your personal time?

I’m a gardener.  I could spend hours at a landscape nursery.

6.     Who is your favorite historical figure and why?

The Wright Brothers because despite the competition and failures they remained enthusiastic and committed to achieving.  They put their money and reputations on the line and subjected their work to hundreds of public trials.  Their character outlasted their business ventures.

7.     What is your favorite junk food?

Brownie edges.  Moist, cake-like brownies are over-rated – chewy and crunchy are the best.

8.     Of what accomplishment are you most proud?

After we had triplets, the support from our family that permitted us some sleep and allowed me to wrap-up my MBA.

9.     For what one thing do you wish you could get a mulligan?

My first month driving a car.  Not good when the insurance agent asks, ’you again?’

10.  What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?

Watching how states will move managed long-term care services to MCOs and how the MCOs will adapt their capabilities to serve consumer direction programs.  Until recently, these programs were untouched by managed care.  States grew the programs and established rules to encourage recruitment and retention of direct care workers.  Under new contracts, MCOs will need to sort out data integrity, provider network and fraud prevention challenges in a politically charged and disruptive environment.  Wage increases and union efforts to organize direct care workers will influence quality.  If you can’t find and keep a good direct care worker, then overall costs go up.  MCOs also will need to test and deploy new electronic visit verification (EVV) fraud tools that states delayed doing this year.

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Clay’s Weekly Medicaid RoundUp: Week of December 31st, 2018

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

 

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

 

READY FOR MEDICAID INNOVATIONS 2019- I will be there again this year (my 9th time), chairing one of the very best Medicaid events you can go to. Also, its sunny Florida in February (I’m looking at you, Michigan). If you decide to go, let me know and we can meet up. Check it out here – https://www.medicaidinnovations.com/

 

PREVIEW OF MONDAY’S MEDICAID NEWS SHOW- We will cover the Texas ruling, state budgets and about a million other things. Not signed up yet? Sign up here for free-

http://bit.ly/2H8xAz1

 

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. Since we’re punting news to the Monday show, lets do a butt-ton of fraud this week. Darrel Bryant and Gifty Kusi of Hillard, Ohio were convicted of stealing $3M from Medicaid for bogus drug cream claims. They were assisted by Jornell Rivera, who is a “doctor” listed as a co-conspirator in the case. Abdi Ali Gure of Bloomington, MN was charged for stealing $260k with a services-not-provided scheme. Laird Richmond and Jason Lowery of Seattle, WA were ordered to pay back $928k they stole by not paying employees the full “sleeping” rate. In WA, if you require staff to stay overnight in a residential facility, you have to pay them a certain rate while they sleep. These 2 yahoos billed the state for the full rate but didn’t pass it onto the staff. Christiana Care (Delaware’s largest hospital system) is back on the radar for yet another fraud scheme. A few years ago the health system settled for $3.3M with the state to make allegations related to shady billing practices in its neonate unit go away.  Now an auditor has surfaced new issues in the past few weeks. Lisa Raymond and Robert Maglicic of Florence, SC were charged with stealing $2M from Medicaid for behavioral health services not provided. Toshirea Jackson of Bridgeport, CT was ordered to pay back the $2.5M she stole using her 2 social services businesses. Seems Mrs. Jackson was stealing the Medicaid IDs of people she was counseling for substance abuse, and then using them to submit false claims. Luis Omar Vargas of Roselle, NJ was convicted for stealing $2M with a dental patient kickback scheme. He paid patients $25 to do a visit (wish I got paid for visits- doesn’t it normally work the other way around? Are we to believe the patients innocent in this? Were they tried? If not, why not? $2M!!!), and then billed Medicaid for boucoup more on bogus claims. Haytham “Tom” Fakih of Deerborn, MI stole $1.2M from Medicaid and Medicare (not eligible for this week’s award, Tom) by billing for expensive meds to dead patients. Mobolaji Stewart of Maryland stole $434k from D.C. Medicaid with bogus personal care aide claims. She even billed for more than 24 hours in a day (now that’s commitment). Fly clear across the country to Alaska to meet Sirje Kulakevich, who stole “more than $50,000” as a personal care aide in the The Last Frontier. Margaret Fisher of the Music City fled to North Dakota, but her $1M Care and Caid behavioral health fraud caught up with her this week. She (and her staff at her direction) forged signatures on counseling session documentation. George Louis Moreno of McAllen, TX plead guilty to a $1.5M DME fraud this week. His crime, lots and lots of bogus claims for incontinence supplies. Messieurs Bryant and Kusi, you win! Something about the $3M worth of cream spoke to me. Taxpayers, you lost at least $18M in that last paragraph ($36,437 per word).

 

Check out the Fraud Curator for the original articles for the adventures above. Also lots of member fraud nuggets in it, too.

Medicaid FWA Curator- Vol 5

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 it ever stops raining) and keep running the race (you know who you are).

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