International Classification of Diseases, 9th Revision, Clinical Modification – A standardized system currently used in the United States that classifies diseases, injuries and external causes by etiology and anatomic location and assigns each entry an identifier that may be up to five alpha-numeric characters in length.
Further reading –
https://www.cdc.gov/nchs/icd/icd9cm.htm
Accountable Care Organization – A network of health care professionals and organizations that band together to provide health care services for a defined population of patients; the network is paid to provide coordinated comprehensive care to patients and assumes responsibility for the cost and quality of that care.
Further reading –
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/
The Qualified Disabled Working Individual (QDWI) program is a state-administered program that pays Medicare Part A (hospital insurance) premiums for disabled people who have gone back to work. There are certain basic requirements you must meet to be eligible. You must:
be under the age of 65
be disabled
be ineligible for free Medicare Part A because your disability benefits were ceased due to working above the SGA limit
be ineligible for state medical assistance (Medicaid), and
meet the income and asset tests in your state.
QDWI pays your premiums for Part A, but it does not pay the Part A deductible or copayments or anything toward Part B. (If your income is very low (under 135% FPL) despite working, you could qualify for a Medicare Savings Program that pays some of these expenses.)
Further reading –
https://www.benefits.gov/benefits/benefit-details/6180
The Programs of All-Inclusive Care for the Elderly (PACE) provides comprehensive medical and social services to certain frail, community-dwelling elderly individuals, most of whom are dually eligible for Medicare and Medicaid benefits .
Further reading –
https://www.medicaid.gov/medicaid/ltss/pace/index.html
Outpatient Prospective Payment System – In response to rapidly growing Medicare expenditures for outpatient services and large co-payments being made by Medicare beneficiaries, Congress mandated that the Centers for Medicare and Medicaid Services (CMS) develop a Hospital Outpatient Prospective Payment System (HOPPS) and reduce beneficiary co-payments.
Further reading
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2988668/
Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2goTIIy
For optimist readers- http://bit.ly/2goyuuo
IT’S BEEN A LITTLE WHILE, PEEPS – Been running the conference marathon. Let’s do this…
IL COULD CUT RETRO-ELIGIBILITY- A proposal to CMS from IL HHS is asking to remove the need to pay for services up to 3 months before a member became eligible for Medicaid (for example if a health emergency hits and they can’t pay for it so they apply for retro-active eligibility). Estimates put this one at saving the state $37M. My question – does it matter if they’re not paying their bills for people who were eligible anyway? See also – IL has a multi-year, multi-Billion backlog to providers and MCOs.
AN ENTITLEMENT BY ANY OTHER NAME WOULD SMELL AS SWEET- The Good Guvnr LePage of the Pine Tree State (Maine) is ruffling the feathers of lefty-birds when he insists on calling Medicaid “welfare” in recent interviews. LePage continues to oppose expansion, much to the chagrin of our Progressive Overlords who know what’s best for state budgets (and of course are better, more moral people than those who care about other budget items). Here, Hear!
MS PROTESTS CONTINUE- The much-maligned managed care awards from the Magnolia state completed the administrative appeals process this week (with the agency affirming its decisions), but there remains a lawsuit to be dealt with. Amerigroup and True Health have raised red flags around lower scoring for some of their responses they think were very similar to winner’s responses.
ARMCHAIR MEDICAID PUNDITS IN D.C. SPECULATE TX MAY EXPAND CAID IN LIGHT OF HARVEY, CHANNELING RAHM’S “NEVER LET A GOOD CRISIS GO TO WASTE”- No one from TX has suggested such (yet anyway). From all the video I am seeing, Texans are pretty self-reliant. Maybe if CMS covers outboard motors under DME?
WELCOME BLAKE TO GA MEDICAID – GA DCH has a new director this week. Blake Fulenwider will start in his new role September 15th.
BE ON THE LOOKOUT FOR THE MONDAY MORNING MEDICAID MUST READS NEXT MONDAY- Absolutely incredible article about interconnected players and companies inside CMS/HHS over past 2 decades.
THE VOX POPULI GIVES THUMBS UP TO MEDICAID WORK REQUIREMENTS- Politico polled about 2,000 people and 51% support tie-ing Medicaid to employment and 37% opposed. Food for thought as CMS weighs a pile of waiver apps to require weekly work hours to get a Medicaid card.
I WILL BE AT MHPA 2017 IN OCT., WILL YOU? You can check it out here – http://bit.ly/2twCi5L Every 100th registrant will get a free Medicaid Foundations Course registration (our online training course).
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. Mark Johnson of Janesville, WI pled guilty this week to stealing $740k from Medicaid using fake scripts. Antoine Skaff of Charleston, WV pled guilty this week to stealing $700k from Medicaid and MCOs for dental procedures not actually provided and for inflating billings for procedures that did actually happen. This one also includes the crowd dental favorite – getting paid for removing the same tooth multiple times. Hin Wong of Manhattan was popped for stealing $15M from NY Medicaid, using an HIV-drug kickback scheme. Ms. Wong spent the ill-gotten gains on plastic surgery, travel and luxury goods. Godwin Oriakhi of TX will spend 40 years in prison for his role in a $17M scheme that bilked both Care and Caid using a home health kickback arrangement (kickbacks were to patient recruiters and physicians). Victor Aldeza, Regino Aldeza, Albert Aldeza, George Aldeza and Lovelyemy Libao (all 5 are siblings) of AK stole $365k from Medicaid by pretending Regino was disabled. Chandra Wrightsell of Lincoln, NE was sent up the river for using her counseling company to file 1,200 false claims. Her tab? $100k. Ms. Wong – you win this week’s award! Total taxpayer tab this week – $33.9M lost to fraud. And remember – say it with me- that’s just the ones that made the news (99% do not). This week.
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 (feel fall coming) 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 Ulın jiberdi
Since its 1976 establishment, the Office of Inspector General of the U.S. Department of Health & Human Services (HHS) has been at the forefront of the Nation’s efforts to fight waste, fraud, and abuse in Medicare, Medicaid and more than 100 other HHS programs.
Further reading
A managed care organization (MCO) is a health care provider or a group or organization of medical service providers who offers managed care health plans. It is a health organization that contracts with insurers or self-insured employers and finances and delivers health care using a specific provider network and specific services and products.
They provide a wide variety of quality and managed health care services to enrolled workers keeping medical costs down through preventative medicine, patient education, and in other ways. These organizations are certified by the director of the Department of Consumer and Business Services (DCBS).
MCOs vary in their constitution as some organizations are made of physicians, while others are combinations of physicians, hospitals, and other providers. For instance, a group practice without walls, independent practice association, management services organization, and a physician practice management company are the common MCO’s.
Further reading
A fiscal intermediary is a private company contracted by Medicare to pay bills – such as hospital expenses – for Medicare Part A and Part B.
Further reading
https://definitions.uslegal.com/f/fiscal-intermediary-fi-health-care/
The Administration for Children and Families (ACF) is a division of the Department of Health & Human Services. We promote the economic and social well-being of children, families, individuals and communities with leadership and resources for compassionate, effective delivery of human services.
Further reading
