Category: Amazing Free Content

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

Or you can click the one for optimist readers –  http://bit.ly/2mQQ9xn

Both are St. Patrick’s Day references. If you know why, do write in.

ONLY A FEW MORE WEEKS UNTIL MEDICAID STAR SEARCH– A plug for our upcoming Medicaid Star Search Webinar on April 3^rd. Sign up here- http://bit.ly/2ccl593

MAYO HONCHO JUST COMES OUT AND SAYS IT- Mayo Clinic’s CEO said privately insured patients will go in front of Medicaid patients, assuming comparable conditions. Both will be seen, but the one who generates more revenue will get seen first. The CEO was heard saying something about needing to keep making money to keep the lights on, and to help subsidize free care – but he was carried off by the villagers with pitchforks before reporters could understand him.

ANTHEM DISTINGUISHING ITSELF FROM REST OF PACK IN POLITICAL ARENA- Last week Anthem was the lone wolf supporting AHCA (AHIP and others came out against it). Now we have news of Anthem CEO Swedish meeting privately with President Trump and Price. The meeting (we expect Rachel Maddow to leak the transcripts next week) covered detailed design elements of the bill, and ideas Anthem has on how to improve it.

THE MEDICA STORY SEEMED TOO GOOD TO BE TRUE– Although at first it looked like an amicable exit,  it turns out the departing MN MCO ain’t going down without a fight. It gets a little convoluted, but basically Medica is arguing that the state did not have a right to transfer its membership to other MCOs without a rebid of the contracts. Seems Medica wanted to pull out saying the rates were not actuarially sound, and then perhaps trigger a rebid which would re-open rate negotiation. The state was more than happy to skip that route and just dole out the remaining membership to the remaining MCOs using rates that were established in 2015. These protests are getting harder to follow  than all the crazy drama of the English wars for the throne in the Middle Ages.

HHS HEAD PRICE SAYS LOSING $BILLIONS WON’T HURT MEDICAID- There’s a lot to chew on in that idea. Not the least of which is the loss to fraud each year, paying for poor quality and other obvious areas to trim. I think this quote from Price should be the starting point of this discussion: “You’re falling into the same old trap of individuals who are measuring the success of Medicaid by how much money we put into it.” Ouch. And Amen.

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.  Ethel Freeman-Nnonah and Tinisee Harris of Reynoldsburg, OH were convicted this week of stealing $101,000 by forging medical assessments and plans of care for patients treated by their business (Prudent Healthcare Services, LLC). “Dr.” Stanley Marable of Valdosta, GA will spend 2 years in prison for his role in pilfering $789k by getting paid for tooth extractions that didn’t happen. Tammie Sensenig of Lancaster, PA plead guilty this week to stealing $84k using Medicaid claims for mental health services she provided but was not qualified to render. “Dr.” Romeo Pavlic of Spokane, WA will pay $300k to settle claims he defrauded Medicare and Medicaid by billing for tests he did not perform on developmentally disabled patients. Stanley – You win!

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 (The weekend will be warmer.) and keep running the race (you know who you are).

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FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: האב שלח את בנו כדי להציל את העולם

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2nmj3V9

Or you can click the one for optimist readers –  http://bit.ly/2nmC8GK

It’s 4am. I have had 2 cups of coffee already. Let’ see what happens.

BEFORE I DO ANYTHING ELSE – A plug for our upcoming Medicaid Star Search Webinar on April 3^rd. This is your chance to hear from 3 companies trying to be innovative in the Medicaid space- without having to sit through a cheesy sales pitch (they each get 10 minutes).  Sign up here- http://bit.ly/2ccl593

I GUESS I’LL TALK ABOUT ALL THIS REPEAL AND REPLACE STUFF. IF YOU WANT ME TO- The best summary I can give is that the bill introduced this week has zero chance because both sides hate it. Multiple conservatives in the Senate have spoken against it, saying its ObamaCare-lite and a failure to deliver on a critical promise to the base to repeal ACA. Lefties have cranked up the fever-pitch-crazy machine, spouting non-stop EVERYONE WILL DIE headlines. The real question is will Ryan be able to throw up his arms and say “well, I tried,” or will Paul, Cruz and others hold him to the fire to put out a bill that repeals ACA even if it has to be Pelosied (ramming it through throats with just enough votes). Another interesting little twist was the CMS CMO coming out against RyanCare. Maybe he and Sally Yates can start a consulting company once he gets bagged in the next month or so? One last note – Verma made it through the Senate yesterday, one step closer to the CMS head job. Everyone I have talked to in our world says she is awesome. I will believe them over fake newsers any day. Unless of course it comes out that she is a Russian CIA spy using my toaster to read my mind (Wikileaks Vault 7 reference for those who don’t read outside of CNN).

AMERIHEALTH AND MERCY HOSPITAL ON THE ROCKS IN HAWKEYE STATE- So far the 2 can’t reach agreements on payment rates. This is part of how the savings happens, people. You pay MCOs to negotiate with behemoth providers for you. There is a similar story happening in MN with BCBS and Children’s hospital.

LAND OF LINCOLN GETS EXPANSION BILL. SURPRISE! IT’S DOUBLE WHAT WAS PROJEKTED. Sadly no one is surprised anymore. There are now 4 things certain in life (updated since I was a child): Death, taxes, MMIS projects failing and Medicaid expansion costs being double what was promised during the sales/shaming into approving phase. IL Medicaid has now spent about $9.2B on expansion, compared to the original projections of $4.6B.

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.  4 numbskulls in Anchorage, AK got popped this week for stealing $1M in Medicaid moo-la. Their crime? Falsifying records to up payments to their nursing home business. Enny Portillo of Highland Mills, NY plead guilty this week to nabbing $75k for personal care services that were not performed. Mrs. Portillo took advantage of NY’s Consumer Directed option to pilfer the cash. Corey Werito and Rosita Toledo (both awesome, and rhyming names!) of Farmington, AZ plead guilty of stealing $2M from Medicaid using their transportation company. Kester Atumonyogo (what is it with the awesome names this week?) of Valley Stream, NY stole $1.5M from Medicaid by using false claims to get paid for enteral nutrition supplies. Mr. Automonyogo- you win, even beating out the team effort by the group in AK! This week’s Roundup Fraud total – $4.6M from taxpaying citizens. And remember – that’s just what I found in the news quickly. At 4AM.

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 (I have 100+ pepper plants already.) and keep running the race (you know who you are).

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FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: hoouna mai ka Makua i ke Keiki e hoola i ko ke ao

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2lRoz5n

Or you can click the one for optimist readers –  http://bit.ly/2lRbJno

THE WHEAT STATE TILTS AT WINDMILLS- Either KS and ME know something we don’t, or these 2 states are about to get approval for Medicaid expansion in the era of Trump. ME got it on the ballot and KS reps just passed it in their house. Or maybe lefty reps in both states are play-acting to look good for their base since Dems in generally are licking wounds right now? You decide. News and Weather at 10.

HEART OF DIXIE WANTS CAID FOR CONS- Err, sorry I meant to say “justice-involved.” Please don’t take away my snowflake card. Senator Cam Ward wants Alabama to get some help from the federalis to cover inmate costs. If his bill goes through, the feds (that translates to “taxpayers in other states”) will pay 70% of the costs of healthcare for Bama’s bad guys.

CONTINUED CHAOS IN UNHINGED WHITE HOUSE WITH DARK VISION OF AMERICA. DOOM! DOOM! DOOM! RUSSIANS! RESIST! Actually, yet another logical, calculated appointment was made to President Trump’s team this week. Brian Blase just joined the staff. Blase is a PhD economist who spent time as a Senate staffer and has been very open about his criticism of current Medicaid financing shenanigans. Couple this with the appointment of Price to DHS and Veerma to CMS- Mr. Trump is not joking about transforming Caid. The Resistance will have to do better than misbehaving at town halls and worshipping Michael Moore if they want to effectively shape what’s coming.

BEAVER STATE SEES DROP IN ENROLLMENT– There’s been about an 11% drop in Oregon Caid enrollment comparing Jan 17 to Mar 16. This translates into 133,000 less managed care members, which = 133k x 12 x the average cap rate less money for the MCOs (CCOs) in Oregon (I do fancy Medicaid math, you should sign a consulting agreement and pay me to do fancy Medicaid math for you. I also put most of my internal thought processes in parentheses [rarely in brackets] {and never in whatever these things are}). That’s a lot less cash the MCOs (CCOs) have to operate and will probably lead to some sort of horse-trading required come rate-setting time.

MOLINA POSTS NY CAID LOSS; RECENT SIGNALS OF EXITING EXCHANGES- Revenues for Molina in NY dropped $185M YOY, resulting in an overall $192M Q4 loss. The main culprit? Having to pay $322M into a risk adjustment pool that then got redistributed to other MCOs who showed higher risk memberships. Molina has also recently begun socializing the idea of it pulling an Aetna and exiting the exchanges.

XEROX (OLD ACS) ASKS JUDGE TO LIMIT THE PAIN IN THE LONESTAR STATE- The flailing MMIS giant has alleged that the state is using “a web of lawsuits” to jack up potential settlements related to that whole debacle over prior auth for orthodontics services for TX Medicaid bennies. Xerox wants to be able to designate the dentists involved as responsible 3^rd parties. TX wants to be able to sue Xerox AND the dentists separately. The suit currently rings up at about $1B in potential payouts.

FARRIS’S FANTASTIC FRAUD FOLLIES– None this week dear readers. I hear you collectively, depressively sighing. But remember- I gave you an entire Roundup of Fraud Follies like 2 weeks ago. Remember that. Hold it close.

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 (its spring. You know its spring.) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Uba ya aiko Ɗan ya ceci duniya

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

Or you can click the Special Valentine’s Day treat for optimist readers –  http://bit.ly/2lyalTX

It’s been a while my dearest readers. As is our custom when returning from hiatus, let’s begin with the normal ending segment…

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.  Maria Navarro and Judith Bench of Orlando are charged with using their special needs school to bill 21,000 bogus Medicaid therapy claims. They billed for 8 hours a day but only had staff to provide 2. Taxpayer tab – $4.5M. Pedro Garcia of Mission, TX was charged this week with submitting Medicaid claims for dead people – to the tune of $300k. John Holland of Miami was CEO of Portneuf Medical Center when he (allegedly) took bribes that facilitated $12M of Medicaid fraud. He plead not guilty this week. Michael Johnston of Broadheadsville, PA got sentenced for pilfering $100k from Medicaid using bogus mental health services claims. Mr. Johnston took the cash and used it cover trips to Jamaica. Stephen Monaco (awesome name), a podiatrist from Haverton, PA was sentenced this week for stealing $4.9M from Medicaid, Medicare and other payers. Dr. Monaco would barter opioids with patients in exchange for them letting him shoot painful (but unnecessary) injections into their feet. Eduard Zavalunov of NYC became the 9^th fraudster to plead guilty in a multi-clinic racket that bribed Medicare and Medicaid bennies (with cash) to undergo unnecessary tests. Taxpayer tab – $70M. Shalonda Suggs of Oklahoma City pled guilty this week to a $200k mental health services not provided scheme. Julia Faigel of Boston, MA was ordered to pay $475k for Medicaid dental fraud. She had TWENTY ONE corporations she used to rob the taxpayers. Robert Windsor of Cumming, GA pled guilty this week of bilking GA Medicaid, KY Medicaid, Tricare and FEHBP (the healthcare federal employees get) for more than $20M. His gig? Medically unnecessary balance tests, electromyography (whatever the heck that is) and qualitative drug screens. IPC – a hospital staffing firm that provides doc labor, also goes by Team Health if you are googling for it- will cough up $60M for defrauding Medicaid and Medicare via upcoding. Dr. Oughatiyan was the whistleblower and he will get $11.4M. Bernard Greenspan of Newark, NJ got $200k in bribes for his role in a $200M fraud scheme. He’s pleading innocent (he’s also 80 years old), but 2 dozen other docs have pled out on this scheme which involved Biodiagnostic Lab Services bribing docs for referalls to Medicare and Medicaid. And now, drum roll (we have a lot of contestants this week!)… Mr. Windsor you win this week’s award for your tenacity and not settling for ripping off just one Medicaid program. Indeed – stealing from both GA and KY sets you apart. I hope you stashed some cigarette money someplace, so you can barter in the slammer.

Sadly, I was able to fill an entire Roundup with fraud follies (with a total of about $384M stolen by my rough count). I could do this each and every week (but that would be boring). And I left out several big ones this week, too. Nothing to see here, move along. Regardless of whether we repeal, replace or repair there will always be this wonderful gravy train for fraudsters. As I pay my taxes in the next month or so, I know that makes me feel good. How about you?

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 (I swear we never have winter anymore here in AL. Must be global warming, or maybe the Russians?) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Papa a voye Pitit la pou konsève pou mond lan

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

Or you can click the one for optimist readers –  http://bit.ly/2irnjDt

WAIT A MINUTE- WHO’S SURPRISED AT THE CURRENT ACA REPEAL EFFORTS? It’s been hated by millions since day 1 (and loved by millions, especially on the left), the GOP has introduced 60+ repeal bills over the last 7 years – and now everyone is floored that one of the first things the Right does once it regains control is renew repeal efforts? The Senate took step 1 of a 10-step procedure to repeal ACA early Thursday morning. Here’s the best guide I have seen so far – http://read.bi/2ipCPji

THE LAND OF OPPORTUNITY STATE PUTS APPLICATION BACKLOG TO REST- AR brought in about 250 temp workers, but they got it done. Back in June there were 100,000 “pieces of paperwork” overdue, including 34,000 or so apps that were 45 days old. At year end (just a few weeks ago – weird), there were no overdue apps. Hey AR – can you send those temp workers over to KS?

SOONER STATE MCD NEEDS ANOTHER $200M TO KEEP THE LIGHTS ON- My crystal ball says they will get it. Just look at last year- when the overall OK budget was $1.3B short, OK Mcd got $1B (which was an increase over the previous year). You silly lawmakers need to just submit to the Mcd dominance of your budgets and move on.

MAGNOLIA STATE NEEDS ANOTHER $75M NEXT YEAR- Backers of the bump point to cuts in prior years, as well as a recent $58M cut in September that addressed lower-than-expected state revenues. It is interesting that the request for more money is happening when MS enrollment is decreasing.

KUDOS TO HPP ON THE KEYSTONE WIN- Health Plan Partners was awarded new membership  in PA this week. The award will expand the HPP PA footprint into 13 more counties, home to nearly 500,000 Mcd members. Congrats HPP!

THE COPPER STATE ANTI-EXPANSION LAWSUIT MOVES FORWARD- Its only been four years of spending money on the 300,000 new bennies, but the AZ Court of Appeals has scheduled the hearing challenging whether the way the Good Guvn’r Brewer unilaterally expanded was legal in the first place.

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.  Family Care Nursing (such a wholesome name!) of Meriden, CT settled this week for $5.3M related to billing for 60 day assessments knowing it was not an RN doing the work. Aretha Derrico was arrested for billing Mcd for $57,000 of home health services not provided in Havana, FL. Randy Crowell of Henderson, NV plead guilty to a $100M Rx reverse-diversion scheme last week. Mr. Henderson had an impressive range – from Utah to NY. How did he do it? He was a licensed wholesale rx distributor, of course. Still wondering what “reverse-diversion” means (I made that up, I think)? Instead of the pills going from legit sources to the black market, Mr. Henderson acquired pills in the black market and sold them to pharmacies. Sort of like money laundering, but with oxycontin. Although the specific hit to Mcd is not enumerated, I am more than impressed with this one. There are wonderful details like the use of lighter fluid to remove labels from bottles. Mr. Henderson – you win this week’s award! I would be interested in acquiring the movie rights to your story, when you get out of the slammer.

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 your pepper seeds. They will need 30 days to germinate, and then that’s March and you want them strong when you put them out in May, right?) and keep running the race (you know who you are).

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FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Pitā sēva dha varlḍa dīkarānī