The Advisory Committee on Immunization Practices (ACIP) comprises medical and public health experts who develop recommendations on the use of vaccines in the civilian population of the United States. The recommendations stand as public health guidance for safe use of vaccines and related biological products.
ACIP was established under Section 222 of the Public Health Service Act (42 U.S.C. § 2l7a) and is governed by its charter .
Further reading –
https://www.cdc.gov/vaccines/acip/about.html
Soundtrack for today’s RoundUp pessimist readers-
Soundtrack for optimist readers
LET’S TALK SHOP AT MEDICAID INNOVATIONS 2018 – I will be in Florida again (7th year for me, I think) for the Medicaid Innovations Conference. If you are going, let’s plan on meeting up. Jan 31-Feb 2, 2018. Check it out here- http://bit.ly/2mbKtl1
IN HONOR OF THE TAX BILL MAKING ITS WAY INTO LAW- Whether you believe the “its evil and terrible – the only thing more terrible are the last 5 Republican bills we promised were the most terrible ever” – nonsense about the developing tax plan, it’s a topic of discussion. Maybe not as big a topic as Stuart Smalley this week, but still- taxes are on most people’s mind (at least the 50% of us that pay taxes) this time of year anyway. So, in honor of taxes (long live King George!): Let’s also look on the spending side. More specifically, the fraudulent spending side.
TO TEE IT UP- The latest GAO report on fraud in Medicare and Medicaid is out this week. You know, the one they put out every year that all of us in the space ignore because it ain’t our money (or whatever reason we use to justify not caring about 10% of the funds meant for these vulnerable members we claim to care so much about just vanishing. Most of my good friends opt for the “but fraud happens in other payer verticals, too” garbage.) This year’s report – out this week – shows $95B lost to improper payments in Medicare and Medicaid. Cue hair-splitting discussion re: fraud vs waste vs improper vs Oh, look a squirrel! GAO is giving CMS credit this year for new investments to fight fraud, notably red-flagging certain provider types, creating a Center for Program Integrity and requiring anti-fraud training. But that’s where the compliment sandwich ends (spoiler- its more of an open faced-sandwich this time). According to GAO, CMS has missed basics like conducting a fraud risk assessment for Care and Caid. And in GAO’s view, this is a big omission. The size and complexity of the 2 programs make this an “Of course there is a huge fraud risk here” issue. Check out the article on this in the twitter feed to make sure and see Kirk Nahra’s comments on anti-fraud data analytics being oversold in the last 20 years. Sobering.
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. Antoine E. Skaff of Charleston, WV stole $735k from Medicaid for dental services over 7,836 acts of fraud between 2011 and 2016. Salomon Melgen of West Palm Beach, FL is in court over $100M he stole from MediCARE using bogus eye visits and tests. Investigators nabbed him using data showing Melgen seeing 100 patients a day and performing procedures in seconds that should take 10 minutes. Kristina Mirbayeva of Brooklyn lead a huge fraud operation (34 defendants, spanning 14 companies and 100 bank accounts) that sent recruiters into soup kitchens and job centers to get Care and Caid members enticed with $40 kickbacks to go to one of their clinics and get a ton of tests done. In 2 short years this netted the bad guys about $146M. Joseph Korzelius of Tryon, NC was sentenced this week for using his counseling business to pilfer $436k from Medicaid. Mr. Tryon used his side job of elementary school guidance counselor to steal students’ Medicaid numbers and submit false bills. Maxim home health in Massachusetts settled with Medicaid this week over stealing $14M by billing for unnecessary services for elderly members (95,000 claims for services not covered). A new report out from the Louisiana DOH shows $717k in payments for dead members between 2013 and 2017. That’s better than the $1.85M paid for dead folks in 2012/2013. Cynthia Stiger and Jacques Roy of Dallas (along with 5 other defendants) just finished up their trial. These 2 stole $374M from MediCare using their bogus home health company. They made up fake plans of care and then the good doc (Roy) would sign off on them so they could bill. Hard to do a tally this week since there’s some big MediCare ones in there. But the clear winner is Kristina. She showed leadership by inspiring a huge team of defendants to navigate a complex web of deceit! But hey- evil Republicans reduce spending. Tax cuts for the 1% Eat the rich.. #Resist!!
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 (pour some salt on your steps) 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: phrabida daisong phra bud pheu banthuk olk.
Qualified Health Plan – Under the ACA, the designation of qualified health plan (QHP) is given to health insurance plans that are sold in the marketplace (exchange). The same basic rules apply to plans sold both in and out of the exchanges: they must be guaranteed issue, follow the ACA’s cost-sharing guidelines, and cover “essential health benefits” with no lifetime or annual maximums.
But in order to be sold in the exchanges, a health plan must also be certified by the exchange as a qualified health plan. In the spring of 2013, health insurance carriers in each state submitted plan designs and pricing to the exchanges – the ones that were approved are considered QHPs. The QHP label is basically an extra layer of consumer protection, one that makes shopping in the exchanges a good idea even for people who don’t qualify for subsidies.
Further reading –
https://obamacarefacts.com/insurance-exchange/qualified-health-plan/
The Association for Community Affiliated Plans (ACAP) is a national trade association representing 57 Medicaid-focused health plans in 26 states. Headquartered in Washington, D.C., ACAP advocates on behalf of its community-affiliated member health plans operating throughout the United States. ACAP’s advocacy work focuses on representing publicly sponsored programs and health care providers who serve vulnerable populations. ACAP also promotes universal access to quality and cost-efficient care.
ACAP members are nonprofit plans that serve public insurance programs and the safety net. Collectively, ACAP plans serve more than 17 million enrollees, which is over 50 percent of individuals enrolled in Medicaid-focused health plans.[1]
Further reading –
https://www.communityplans.net/
Alternative Benefit Plan – States have the option to provide alternative benefits specifically tailored to meet the needs of certain Medicaid population groups, target residents in certain areas of the state, or provide services through specific delivery systems instead of following the traditional Medicaid benefit plan. Key Requirements of the Rule Include:
The term 1937 Medicaid Benchmark or Benchmark Equivalent Plan has been retitled to Alternative Benefit Plans.
ABPs must cover the 10 Essential Health Benefits (EHB) as described in section 1302(b) of the Affordable Care Act whether the state uses an ABP for Medicaid expansion or coverage of any other groups of individuals.
Individuals in the new adult VIII eligibility group will receive benefits through an ABP.
Further reading –
Applied Behavioral Analysis – ABA is an empirically validated approach to improve behavior and skills related to core impairments associated with autism and a number of other developmental disabilities. ABA involves the systematic application of scientifically validated principles of human behavior to change inappropriate behaviors. ABA uses scientific methods to reliably demonstrate that behavioral improvements are caused by the prescribed interventions. ABA is presently considered the gold standard of autism interventions.
ABA’s focus on social significance promotes a family-centered and whole-life approach to intervention. Common methods used include: assessment of behavior, caregiver interviews, direct observation, and collection of data on targeted behaviors.
A single-case design is used to demonstrate the relationship between the environment and behavior as a means to implement client-specific ABA therapy treatment plans with specific goals and promote lasting change. ABA also includes the implementation of a functional behavior assessment to identify environmental variables that maintain challenging behaviors and allow for more effective interventions to be developed that reduce challenging behaviors and teach appropriate replacement behaviors.
Further reading –
https://www.hca.wa.gov/assets/billers-and-providers/ABA-services-20161001.pdf
Actual Acquisition Cost – In accordance with the Affordable Care Act and requirements of §447.512(b) of the final regulation, states’ reimbursement for ingredient costs for brand and certain multiple source drugs (that do not have a FUL calculated), will be established as an aggregate upper limit based on AAC, as opposed to an estimated acquisition cost. AAC is defined at §447.502 of the final regulation as the agency’s determination of the pharmacy providers’ actual prices paid to acquire drugs marketed or sold by specific manufacturers. CMS believes that changing this definition of
ingredient cost reimbursement to AAC will provide a reference price consistent with the dictates of section 1902(a)(30)(A) of the Act.
Further reading –
https://www.medicaid.gov/federal-policy-guidance/downloads/smd16001.pdf
Comprehensive Medicaid Integrity Plan – Section 1936(d) of the Social Security Act directs the Secretary of Health and Human Services (HHS) to establish, on a recurring 5-fiscal year basis, a comprehensive plan for ensuring the integrity of the Medicaid program by combatting fraud, waste, and abuse. This Comprehensive Medicaid Integrity Plan sets forth the strategy of the Centers for Medicare & Medicaid Services (CMS) to safeguard the integrity of the Medicaid program.
Further reading –
https://www.cms.gov/Regulations-and-Guidance/Legislation/DeficitReductionAct/Downloads/cmip2014.pdf
The Office of Management and Policy (OMP) mission is to provide management, guidance, and resources in support of OIG. Our vision is to be the best at what we do. OMP is focused on customer satisfaction, reliability, innovation, and continuous improvement. We oversee a diverse portfolio, which includes:
budget formulation, execution, and funding of the State Medicaid Fraud Control Unit grant program; human capital planning, including recruiting, staffing, training, and performance management; information technology solutions, including the complete life cycle for each solution from project initiation, implementation, security, support, policy, maintenance, and decommissioning; and administrative services, including space management, acquisitions/procurement, travel, policies, and emergency preparedness.
Further reading –
https://oig.hhs.gov/about-oig/about-us/office-of-management-and-policy.asp
The Office of Audit Services (OAS) conducts independent audits of HHS programs and/or HHS grantees and contractors. These audits examine the performance of HHS programs and/or grantees in carrying out their responsibilities and provide independent assessments of HHS programs and operations. These assessments help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. OAS conducts audits using its own resources and oversees audit work performed by others. OAS is the largest civilian audit agency in the Federal Government. OAS conducts its work in accordance with Government Auditing Standards issued by the Comptroller General of the United States; the Single Audit Act Amendments of 1996; applicable Office of Management and Budget circulars; and other legal, regulatory, and administrative requirements.
Further reading –
https://oig.hhs.gov/about-oig/about-us/office-of-audit-services.asp
