Category: Amazing Free Content

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

 

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

 

MEGA RULE MUTATES- After a loooooong windup and much speculation, CMS finally showed its cards on possible changes to the Mega Rule. (Do you get the feeling they wait until early November for big stories just to make sure there are interesting convos in the NAMD hotel happy hours?) Highlights: Possible relief on cert for all those rate cells (may go back to ranges), 3 years to put on your big-boy pants related to pass-through payments, and more grace on using telehealth to meet network standards. And oh yeah – some stuff about making sure all you turkeys stop using different rate cells to game the federal match.

 

IL CRIES UNCLE- Following many other states (who are following judge’s orders in their own states), the Land of Lincoln (R-IL) has decided to open the floodgates on Hep-C coverage. Now no signs of disease or proof of sobriety are required to get the pills that cost about the same as a souped-up Civic. But hey- it used to be a new Vette.

 

MICHIGAN GETS TREATED LIKE AN ADULT- Add a W to the win column in the “restore a modicum of power back to the states game.” CMS approved Michigan’s request to negotiate their own deals for pricy drugs based on whether they actually work for the patient. This CMS approval comes 4 months after a similar gig for OK and a denial for MA. Right now the MI deal is focused on 4 drugs. I’m sure the list will expand, and if you say the magic words – “value-based-care,” “population health,” and“big data,” – four times fast, under a fool moon, wearing green slippers, the list of the next 4 drugs will magically appear in your left hand (if you’re left handed; else, your right hand).

 

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. Idris Talib of Columbia, SC got five years in the slammer for stealing $400k using false claims for counseling. Head on up 1 state to NC, where we meet Renee Borunda, who managed to steal $225K using another therapist’s billing ID for Medicaid claims that didn’t happen. Keep heading north until we get to Niagara Falls, NY (cool place if you haven’t ever visited), and we learn about Sadat Khan who used Wego Taxi Tours to steal $50k from Medicaid. How did he do it you ask? By falsifying pickup location addresses so the trips would appear longer and get more mileage reimbursement. Lets drop down to the paradise known as Detroit for our next shining light of Medicaid fraud- Jacklyn Price. Ms. Price and buddies stole $8.9M from Medicare (so can’t win today, sorry!) using a home health scheme. Over in Brooklyn, Yvette Juarez was picked up on a pretty decent-sized member fraud. She made too much money from her daycare business to be eligible for Medicaid, but falsified income statements in order to get about $72k in benefits. Now on to PA- 4 people operating “Moriarty Consultants” stole as much as $87M from Medicaid by fabricating personal care services claims. It gets good, in addition to boring stuff like faking timesheets, they made up employees and paid kickbacks to bennies to help pull it off (remember, fraud is most effective when you work as a team). Team Moriarty – you win! Your creativity and volume put you over the top; you do not live up to your namesake, however.

Taxpayer tab for this paragraph – about $96M. Work harder- and don’t complain or have bad thoughts about it, or else you’re a meanie!

 

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 (enjoy the early winter: apparently there are less sun spots right now?) 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 .

 

Want the Curator News Pack for this week’s Roundup? Medicaid News Curator Volume 2

Here’s the one for the fraud stuff

 

Trystero: Oče je poslal Sina, da reši svet.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2SVN6DU

 

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

 

VOTERS DECIDED TO GROW MEDICAID IN 3 STATES; SHOT IT DOWN IN 1- Idaho, Nebraska, and Utah all decided to “cover” more people with Medicaid (and to spend more money from the pockets of the people who voted against it (40% against in Idaho, 47% against in Nebraska, and 46% against in Utah). But hey – screw those guys! We voted yes, and now they have to pay for it. Losers buy!. 

IN RELATED NEWS, VA IS SHORT $460M IN ITS MEDICAID BUDGET- Sort of related, anyway. These are “unforeseen” costs that occurred before the expansion decision. I wonder if they would have disclosed these costs before the expansion decision, would that have impacted the expansion decision? Current theories as to the overage are higher costs under managed care than expected, and higher than expected CHIP enrollment. Most legislators in the state are already messaging that school spending in next year’s budget will have to go down to pay for this whoopsie.

 

MORE CONSOLIDATION IN THE IL MCO MARKET- Harmony and Meridian health plans are merging after the recent WellCare acquisition of Meridian for $2.5B. Harmony was struggling and was dinged back in May for having insufficient network.

 

CMS WORKING ON NEW RULE FOR STATE FLEXIBILITY ON NEMT- According to a notice of proposed rulemaking last week, CMS is cooking up a new reg that will give states some relief on how much they have to spend on non-medical transportation for Medicaid bennies (states have been asking for this for years, with AZ being the most current example I am aware of).

 

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. Get out your wallets taxpayers – we have some Medicaid fraud to pay for! ImmediaDent (a dental provider with a weird name) and Samson Dental Partners of KS have settled false claims allegations with three states (KY, IN and OH- I guess they didn’t want to fraudulate in their own state?) for $5M. What did they do? Billed simple extractions as surgical procedures, billed scale and root planings that never happened and put dental employees on volume-based commission plans. Sophia Eggleston of Detroit was convicted this week for her role in an $1M home health fraud scheme hitting the Medicare coffers. Travis Moriarity of Pittsurgh (and 3 of his buddies) were charged with defrauding PA Medicaid out of $87M this week. How did they rack up such a bigly fraud, you ask? With bogus claims for personal care services, care coordination and NEMT. If you want to hit the Medicaid fraud big leagues, you’ve got to diversify, people! Bernard Oppong of Blacklick, OH was charged with a pharmacy scheme. Oppong would partner with a pharmacy to send special medical crème to Medicaid members without ever examining them. So far all I have is that this is a “multi-million dollar” fraud… Pretty big whopper of a hospice fraud concluded this week when Patricia Armstrong of Coppell, TX plead guilty to her role in the $60M scam. Armstrong and others stole from Medicare and Medicaid by signing up bennies who didn’t need hospice and then billing for it. They forged terminal-illness certifications. Celestine “Tony” Okwilagwe, et al of Garland, TX were convicted for stealing $3.7M from Medicare and Medicaid using a home health scam. Bonus points- they were already barred from participating in any federal healthcare program. Jennifer Gardner of Summit Township, PA got $104k in member/provider fraud bucks illegally. Let me unpack this one: Ms. Gardner had one of these deals where Medicaid gives you cash to pay your own personal caretaker in your home. But her attendant moved away, she didn’t replace him and kept cashing the checks. Ms. Gardner, you win! You gave us a great illustration of the clear risks of this model! Thank you. Taxpayers, you lost about $159M in this 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 (do the first round of leaf-raking) 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 .

Want the Curator News Pack for this week’s Roundup? Here you go- Medicaid News Curator Volume 1

Here’s the one for the fraud stuff

Trystero: Otec poslal Syna, aby zachránil svet.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2zqq6nM

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

 WELCOME, MRS. MAYHEW- After bringing some predictability to the Maine Medicaid budget, Mary Mayhew was tapped to head Medicaid efforts at the federal level earlier this month. Her official title will be CMS Deputy Administrator. Congratulations, Mary!

BADGES? WE DON’T NEED NO STINKIN’ BADGES- If you thought CMS was holding the phone on work requirements while the KY lawsuit sorts out, you were wrong. CMS approved Wisconsin’s request to add a work requirement feature to its Medicaid benefits package. Also important- Wisconsin is a non-expansion state (many work requirements resisters have been holding out hope that CMS won’t approve work requirements in non-expansion states). CMS did not approve the state’s request to add drug testing requirements for members, but they did allow them to ask bennies about risky health behaviors as part of coverage determinations.

  

NEITHER DOES VIRGINIA- Sources say VA officials plan to submit a work requirements request to CMS by this Friday. Current proposal includes work/volunteer requirements (or job classes) and premiums up to $10/month. Many conservative lawmakers feel the new proposal is too watered down to matter, though.

 

 POSSIBLY ALSO NEITHER DOES MISSISSIPPI- MS Medicaid officials are chatting it up with CMS now that the public comment period on their work requirements request has ended.

  

NEBRASKA VOTERS TO DECIDE EXPANSION AS WELL AS WHICH MODIFIERS SHOULD PAY ON 99213 CODES IN THE NEXT VERSION OF THE POLICY MANUAL- Initiative 427 puts Medicaid expansion in the hands of Nebraskans next Tuesday. I’m not concerned they are low-informed voters on the details of Medicaid. Not at all. Nothing to see here. Move along.

 

 VERMA TROLLS MEDICARE-FOR-ALL MOB; THEY TAKE THE BAIT- Hey if Nebraskans who mostly probably don’t know the difference between Medicare and Medicaid can decide whether to double spending on it, why can’t the twitterverse tell CMS Administrator Verma (in the very polite ways we have come to expect from our leftist friends, of course) she was a terrible, doubleplus ungood person to tweet this in the spirit of Halloween. Remember, questions like “how would we pay for it?” and “does this even make basic logical sense?” don’t matter. All that matters is feelings and a deeply held conviction of a virtuous “resistance.”

 

OHIO MOVING UP HEP-C TREATMENT- Medicaid bennies in OH no longer have to wait until their Hep-C progresses to get specialty drugs. Starting Jan 1, OH will pay for treatment for any one diagnosed with Hep C. In tech speak, OH used to pay for patients with a Fibrosis Score (F score) of F2. Now the state will pay for all Fscores (starting at F0). Last year the state went from only paying for F4s to F2s.

  

CA PAID $4B OUT IN “QUESTIONABLE” PAYMENTS- Some pretty egregious examples in a recent state auditor’s report. Biggest findings – state kept paying MCOs and docs for services for 453,000 members who were ineligible for benefits. Worst example- an MCO got paid $383k for care for a member in LA County who had been dead for 4 years.

  

FINALLY, AFTER 300 YEARS, CMS APPROVES NC WAIVER- Congrats to the team that’s been working on bringing managed care to the state for the past few years!

 

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. Edwardo Yambo of Lake Grove, NY stole $939k for false lab claims. In addition to billing for claims his lab wasn’t even equipped to run, Mr. Yambo operated the lab without a director (a big no-no). Lanice Stamps and Tia Smiley of New Orleans were convicted this week for their $1.1M fraud in Louisiana using a bogus behavioral health company to steal from Medicaid. Bonus – both fraudsters were also Medicaid bennies. Not sure I have seen double-dipping on the provider and benny fraud side before. Nikkita Chesney of Bridgeport, CT plead guilty this week to using 150 stolen member IDs to file more than $1M in false claims. Celestine “Tony” Okwilagwe lead the way in convictions for a pretty large home health fraud in Dallas this week. Along with 3 of his buddies, Tony got popped for stealing $3.7M from Medicare and Medicaid. Special points on this one since 2 of these dudes had already been excluded from any federal health-care program for prior convictions. Matthew Neiswanger of Baltimore was in court last week and agreed to pay back $2.2M his nursing home stole from Medicaid. How did he do it? Evicting higher cost patients (sicker) and false claims. Joseph Dubin and David Dubin (father and son, a first for the follies) of Austin, TX were convicted of stealing $300k in a kickback scheme involving Medicaid psychology services. Fraudster and Sons paid another fraudster to refer Medicaid kids to their mental health services company. Lanice and Tia you win – I am just entranced by the double provider/member fraud angle! Plus, $1.1M is a pretty good take home. Taxpayers, you lose – about $8.2M in the stories covered in this paragraph. Work harder! Gotta pay for all that fraud somehow…

New content alert- The Medicaid Fraud, Waste and Abuse Curator Volume 1 is out. Includes links to the stories above and a lot more. Check it out here.

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 (clean your chimney, its that time already) 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.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2RI7RCi

For optimist readers- http://bit.ly/2RKh1hW

 

BUCKEYES TO GET MORE OPTIONS ON OPIOID RECOVERY MEDS- Based on what I am hearing, looks like Ohio may be removing prior auth for more drugs besides just suboxone and generics for buprenorphine and naloxone. If you know more, please dial into the show on Monday and weigh in.

 

NEW PROJECT TO UP CAID IMMUN RATES- If you’ve been around this Medicaid world a while, chances are you have bumped into the immunization “registries” (glorified excel files in a Medicaid official’s computer, usually). The CDC is funding a new consulting project (Nat’l Academy for State Health Policy got $800k) to figure out how to better integrate this data, encourage providers to submit more of it and close gaps for certain vaccines (i.e. Medicaid rotavirus rates for kids are 12 points lower than commercial).

  

MORE RUH-ROHS IN THE OH PBM SCANDAL- We will cover this in Monday’s show, so tune in. The gist: turns out one of the reasons Centene’s rx costs were more than other MCOs (all of them got caught up in the spread pricing scandal), is because they used their subsidiary (Envolve) as a sort of middle-middle man to the PBMs.

  

HOW MANY YEARS IS IT OK TO NOT HAVE A MEDICAID INSPECTOR GENERAL IN A STATE? 4 years is the answer if you’re Kansas. After the top Medicaid oversight spot (over the $3B program- but hey that’s chump change when its those taxpayer chumps funding it, right?) sat empty since 2014, the seat is now being manned (wo-manned, actually) by Sarah Fertig. Congratulations, Sarah!

 

CONGRATS TO OUR FRIENDS AT WELLCARE- It’s the time of year where we see which MCOs are doing better per NCQA quality ratings, and Wellcare just got high marks in NJ and NY. Congrats!

  

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. Vicki Chisam of Batesville, AR was charged with her role in a $2M Medicaid fraud (part of the Preferred Family Healthcare mental health scheme we have covered). Chisam was apparently the EHR data manipulation specialist in the crimes. She herself is tied to $589k in pilfery. Lyubov Beylina of Brooklyn (along with 7 other upstanding citizens) was charged with stealing $600k for billing for therapy while on vacation in the Dominican Republic. She also forged signatures of parents of children she was therapy-ing. Joanna Michelle Phillips of Cheyenne, WY was sentenced to 18 months for stealing $58k via false claims. Mercy Ainabe of Houston, TX was sentenced this week for her role in a patient recruitment Medicaid fraud scheme. She and her fellow fraudsters used a home health care front to bill for medically un-necessary services, pay bennies to sign-up and send kickbacks to docs. Total tab – $3.6M (but to Medicare, so she can’t win this week). Epo Onega of Staten Island was popped for using her teaching job to steal $59k with bogus speech therapy claims. Vicki- you win! Hopefully you can re-connect with some of your old workmates once you all get sentenced. Taxpayers – you lost about $7M in this paragraph! Work hard! Somebodies gotta pay for all this fraud (hint- you do, chumps). Are you a Medicaid bennie on a waiting list for a waiver program? Keep waiting! Sorry, we have to make sure we keep paying fraudsters before we open up your slot.

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 (plant mums – they can actually do really well in the ground) 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: Otac je poslao Sina da spasi svet. Also – chuir an t-Athair am Mac gus an saoghal a shàbhaladh.

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

For optimist readers- http://bit.ly/2xIBDi9

LET’S SHAKE IT UP A BIT- And do the fraud follies first this week..

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. Husband and wife duo John and Diane Sink of Cheyenne, Wyoming plead out this week to $6.2M in Medicaid fraud. Their charge? Bogus group counseling bills for sessions that included coloring, karaoke, eating at restaurants and shopping. Nagy Mohamed Abdelhamed of York, PA got popped this week for member fraud (we are seeing more of these- is it more frequent, or just less taboo to talk about?). Mr. Abdelhamed’s case appears egregious – he received $1,124 a month in social security disability bucks and collected $30k worth of Medicaid and SNAP benefits in 2018. Problem is, when he applied for Medicaid (in 2014) he only listed $1k in cash assets, no monthly income and no property. Well- he owned a gas station, a Mercedes Benz E350 and has loads of dough in the bank ($58k at time of writing). Timing? He sold the gas station for $172k in the same month he applied for Medicaid. Richard Quitoni of Middletown, NY was charged with a $200k Medicaid fraud. Mr. Q submitted false claims for cab rides for Medicaid bennies, including some doozies for $50 tolls (they’re not that high anywhere in the Big Apple). Mi Ran Yu of Anchorage, AK was sentenced to 8 months in the slammer this week. Her crime? Stealing $90k using false personal care assistant claims. Aleah Mohammed of Queens used her multi-location pharmacy biz to steal $7.9M by submitting false claims to Medicaid (and Medicare). The bogus scripts were either not dispensed to patients, prescribed as claimed or medically necessary. Sonjay Fonn and fiancée (they’re practicing for husband-wife fraud capers) Deborah Seeger of Cape Girardeau, MO stole $1.6M from Medicaid (and Medicare). This one’s fun- Sonjay did spinal fusion surgeries and ordered all his spinal implants from lovey’s DME company. Problem is, lovey got 50% commission on all sales. Lovey then took the Medicaid bucks and bought her handsome prince a yacht and construction projects. John Bradley of Oklahoma City got 8 weeks in jail for stealing $180k in Medicaid bucks. He submitted a slew of false claims for counseling his niece and nephews. Health Management Associates (the hospital chain, not the consulting firm) will pay $260M to resolve claims it paid kickbacks to docs so they could rip off Medicare and Medicaid by ordering unnecessary tests and increasing admits from the ED.

Mr. and Mrs. Sink, you win this week’s award with a respectable $6.2M Medicaid fraud! Taxpayers, you lose…Total tab in this paragraph is around $278M by my count. Work harder, taxpayers – someone has to pay for all this fraud!

 

OK, NOW SOME QUICK NEWS HITS- For all you fraud junkies, was that like eating dessert first?

MRS VERMA DEFENDS WORK REQUIREMENTS – Seema spoke at a conference in D.C. yesterday and let folks know CMS is maintaining its ground on this, despite all the pearl-clutching.

SHE ALSO LET MCOS KNOW A BIG OLE’ MICROSCOPE IS COMIN’- Clients (and anyone who has been around me the past few years) know I have been saying this is coming since the Mega Reg dropped. An MLR-audit is a natural conclusion of the MLR floor, and it will give CMS a simple way to take back cash.

OREGON CONSIDERING NON-COVERAGE OF NEXT-GEN SEQUENCING TESTS– These are tests used in cancer treatment. Medicare just covered it, but OR Medicaid is studying whether the tests are ready for prime-time just yet. The latest report from the OR Medicaid committee studying effectiveness has a clear non-coverage recommendation. Analysts are watching this one because it could be a model for other state Medicaid programs concerned about the costs of these tests.

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 (marvel at the changing of the seasons) 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: Na auina mai e le Tama le Alo e laveai le lalolagi.