Category: MM Curator

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OP ED- Medicaid Expansion Won’t Stop Rural Hospital Closures

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Turns out the Aace in the hole used by far left-wing activists to force Medicaid expansion is really a Joker.

 
 

Clipped from: https://www.wsj.com/articles/medicaid-expansion-wont-save-rural-hospitals-obama-care-fraud-dependency-e9ad20c7

But it has disastrous consequences for state budgets and fosters high levels of dependency.

Democrats think they’ve found the key to convincing Republican states to expand Medicaid and cover millions more able-bodied adults in the government-run health-insurance program. Over the past few years, Democrats have claimed that refusing to accept ObamaCare’s central policy will force the closure of rural hospitals, hurting GOP states and voters the most. This tug-at-the-heartstrings message has swayed Republican-dominated states such as South Dakota, Missouri and, as of late March, North Carolina to expand Medicaid. But it’s a lie.

I have analyzed every hospital closure since 2014 when ObamaCare went into effect. Medicaid expansion has failed to halt rural hospital closures, and in some cases it contributes to them. The reason is simple: Medicaid is so poorly run that it often adds financial burdens to hospitals. The 10 Republican-led states that haven’t adopted this policy would be wise to hold their ground, given that Medicaid expansion also has disastrous consequences for state budgets and fosters historic levels of government dependency.

 
 

Here are the facts. Since 2014, dozens of hospitals have closed in states that haven’t expanded Medicaid. Yet their stated reasons almost always have nothing to do with Medicaid expansion. Damage from natural disasters, declining business and fraud, among many other factors, have caused hospitals to close. Only four hospitals in nonexpansion states directly attributed their closures to a lack of Medicaid expansion. Two of them later were alleged to have engaged in wide-scale fraud and financial mismanagement, casting doubt on their earlier statements.

Even more telling is what happened in the nearly 40 states that did expand Medicaid before the start of this year. Despite the assurances of liberal activists, nearly 50 hospitals have closed in these states since expansion passed, including more than a dozen in rural areas. Missouri voted to expand Medicaid by ballot initiative in August 2020, with implementation beginning a little more than a year later. Yet two rural hospitals closed in September 2022, well after expansion took effect.

 
 

The situation will surely worsen. According to data from the Center for Healthcare Quality and Payment Reform, 1 in 4 rural hospitals in expansion states are still at risk of closure. A 2019 Navigant study found that the top five states at risk of losing community-essential rural hospitals are all expansion states.

This is exactly what Medicaid expansion was supposed to prevent, yet expansion itself is driving this crisis in rural and urban hospitals alike. The program’s reimbursement rates are about 60% of what private health insurance pays, often leaving hospitals with large losses on Medicaid patients. Nationwide, more than 18 million able-bodied adults and counting have enrolled in the program due to expansion, and each new recipient potentially adds red ink to a hospital’s balance sheet.

Rural hospitals typically struggle financially as it is, and Medicaid expansion can push them into insolvency. But the problem isn’t limited to rural hospitals. Pennsylvania expanded Medicaid in 2015 and Philadelphia’s Hahnemann Hospital closed in 2019 because of what the Philadelphia Inquirer called a “heavy reliance on Medicaid.”

Despite these closures, hospital advocacy groups have joined Democrats in vigorously demanding expansion. The promise of federal money in the short term—and the resulting bonuses and pay bumps for hospital executives—is apparently more important than future stability.

Democrats won’t stop until they convince all 50 states to expand Medicaid. As one activist told the New York Times in March, “this argument about rural hospital closures has been an incredibly compelling argument to voters.” That same story, which focused on Mississippi, was titled “A State’s Choice to Forgo Medicaid Funds Is Killing Hospitals.” Mississippi and Alabama are likely the next two states in Democrats’ sights.

The remaining Republican-led states shouldn’t fall for it. By not expanding Medicaid, they are likely saving rural hospitals from even worse financial pressure, while protecting taxpayers from enormous losses and saving able-bodied adults from government dependence. In these states, at least, the truth about Medicaid expansion still prevails.

Mr. Dublois is data and analytics director at the Foundation for Government Accountability.

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From <https://www.wsj.com/articles/medicaid-expansion-wont-save-rural-hospitals-obama-care-fraud-dependency-e9ad20c7>

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GAO Makes MACPAC Appointments, Designates Vice Chair

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Welcome the next cohort of MACPAC(kers).

 
 

https://www.gao.gov/press-release/gao-makes-macpac-appointments,-designates-vice-chair-0

 
 

 
 

Press Release WASHINGTON, D.C. (May 1, 2023)—Gene L. Dodaro, Comptroller General of the United States and head of the U.S. Government Accountability Office (GAO), today announced the appointment of six new members to the Medicaid and CHIP Payment and Access Commission (MACPAC). He also named the Commission’s Vice Chair.

“I’m pleased to announce the newest members of this important health care commission,” Dodaro said. “These outstanding individuals are exceptionally well-qualified to serve and provide Congress with expert advice on both Medicaid and the Children’s Health Insurance Program (CHIP).”

The newly appointed members are Timothy Hill, Carolyn Ingram, Patti Killingsworth, Adrienne McFadden, and Jami Snyder. Their terms will expire in April 2026. In addition, John B. McCarthy was newly appointed to serve out the remaining term of Laura Herrera Scott, which will expire in April 2024. Current member Robert Duncan has been named the Commission’s Vice Chair.

The Children’s Health Insurance Program (CHIP) Reauthorization Act of 2009 established MACPAC to review Medicaid and CHIP access and payment policies and to advise Congress on issues affecting Medicaid and CHIP. The Act directs the Comptroller General to appoint MACPAC’s members. Brief biographies of the new commission members and the Commission Vice Chair follow.

New Commission Members:

 
 

 
 

Timothy Hill, MPA, is Vice President for Client Engagement at the American Institutes for Research (AIR), where he provides leadership and strategic direction across a variety of health-related projects. Prior to joining AIR, Mr. Hill held several executive positions within the Centers for Medicare & Medicaid Services (CMS), including as a Deputy Director of the Center for Medicaid and CHIP Services, the Center for Consumer Information and Insurance Oversight, and Center for Medicare. Mr. Hill earned his bachelor’s degree from Northeastern University and his master’s degree from the University of Connecticut.

 
 

Carolyn Ingram, MBA, is an Executive Vice President of Molina Healthcare, Inc., which provides managed health care services under the Medicaid and Medicare programs, as well as through state insurance marketplaces. Ms. Ingram is also the Plan President for Molina Healthcare of New Mexico and the Executive Director of the Molina Healthcare Charitable Foundation. Previously, Ms. Ingram served as the Director of the New Mexico Medicaid program, where she launched the state’s first managed long-term services and supports program. She also held prior leadership roles, including Vice Chair of the National Association of Medicaid Directors and Chair of the New Mexico Medical Insurance Pool. Ms. Ingram earned her bachelor’s degree from the University of Puget Sound and her master of business administration from New Mexico State University.

 
 

Patti Killingsworth is the Senior Vice President of Long Term Services and Supports (LTSS) Strategy at CareBridge, a value-based healthcare company dedicated to supporting Medicaid and dual eligible beneficiaries receiving home and community-based services. Ms. Killingsworth is a former Medicaid beneficiary and lifelong family caregiver with 25 years of Medicaid public service experience, most recently as the longstanding Assistant Commissioner and Chief of LTSS for TennCare, the Medicaid agency in Tennessee. Ms. Killingsworth received her bachelor’s degree from Missouri State University.

 
 

John B. McCarthy, MPA, is a Founding Partner at Speire Healthcare Strategies, which helps public and private sector entities navigate the healthcare landscape through the development of state and federal health policy. Previously, he served as the Medicaid Director for both the District of Columbia and Ohio, where he implemented a series of innovative policy initiatives that modernized both programs. He has also played a significant role nationally, serving as Vice President of the National Association of Medicaid Directors. Mr. McCarthy holds a master’s degree in public affairs from Indiana University’s Paul H. O’Neill School of Public and Environmental Affairs.

 
 

Adrienne McFadden, MD, JD, is the Chief Medical Officer of Medicaid at Elevance Health, where she serves as the strategic clinical thought leader for the Medicaid line of business. Previously, Dr. McFadden was the Chief Medical Officer at Buoy Health, a virtual health service created to support patient decision making. After beginning her career in emergency medicine, Dr. McFadden has held multiple executive and senior leadership roles including Vice President for Medicaid Clinical at Humana, Inc.; Director of the Office of Health Equity at the Virginia Department of Health; and inaugural Medical Director of the South University Richmond Physician Assistant Program. Dr. McFadden received her medical and law degrees from Duke University.

 
 

Jami Snyder, MA, is the President and Chief Executive Officer of JSN Strategies LLC, where she provides health care-related consulting services to a range of public and private sector clients. Previously, she was the Arizona cabinet member charged with overseeing the state’s Medicaid program. During her tenure, Ms. Snyder spearheaded efforts to stabilize the state’s health care delivery system during the public health emergency and advance the agency’s Whole Person Care Initiative. Ms. Snyder also served as the Medicaid director in Texas and as the President of the National Association of Medicaid Directors. Ms. Snyder holds a master’s degree in political science from Arizona State University.

Commission Vice-Chair:

 
 

Robert Duncan, MBA, is Executive Vice President and Chief Operating Officer of Connecticut Children’s. Previously, he served as Executive Vice President of Children’s Wisconsin and the President of Children’s Service Society, a large social service agency that provides foster care and adoption, mental health, and parental support services to children and families across the state. Earlier, he served as both the Director of the Tennessee Governor’s Office of Children’s Care Coordination and the Director of CoverKids, Tennessee’s CHIP program. Mr. Duncan received his master of business administration from the University of Tennessee at Martin.

For more information about MACPAC, contact Kate Massey, MACPAC’s executive director, at (202) 350-2000. Other questions should be directed to Chuck Young in GAO’s Office of Public Affairs at (202) 512-4800. 

 
 

From <https://www.gao.gov/press-release/gao-makes-macpac-appointments,-designates-vice-chair-0>

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MH/BH- How to Protect Integration Progress As Medicare-Medicaid Plans Sunset

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: We sort of don’t have a plan to keep Medicare/Medicaid integration going.

 
 

 
 

Clipped from: https://healthpayerintelligence.com/news/how-to-protect-integration-progress-as-medicare-medicaid-plans-sunset

With Medicare-Medicaid plans set to sunset by the end of 2025, states, CMS, Congress, and other stakeholders must take steps to protect the Medicare-Medicaid integration progress.

Source: Getty Images

 
 

By Kelsey Waddill

May 03, 2023 – As CMS sunsets the Medicare-Medicaid plan model, Congress and the agency will need to take steps to expand the Medicare-Medicaid Coordination Office (MMCO) oversight capabilities and protect the previous years’ Medicare-Medicaid integration progress, researchers explained in a Health Affairs article.

CMS is sunsetting the Medicare-Medicaid plan model nationwide. The agency found that the program was inconsistent. In some cases it increased utilization while in other cases it decreased utilization. The Medicare-Medicaid plan will be dissolved nationwide by the end of December 2025.

States will have to determine how to transition their Medicare-Medicaid plan populations into meaningfully integrated dual eligible special needs plans, such as highly integrated dual eligible special needs plans (HIDE SNP) and fully integrated dual eligible special needs plans (FIDE SNP).

There are 11.5 million individuals with access to a dual eligible special needs plan or Medicare-Medicaid plans. Less than half are enrolled in one of these options (5.1 million). The sunsetting of the Medicare-Medicaid plan model in one state (California) drove down enrollment in meaningfully integrated programs.

Some states have models that will provide a more natural transition into meaningfully integrated plans. For example, eight states offer a capitated Medicare-Medicaid plan and certain counties in two of these states offer parallel Medicare-Medicaid plans and FIDE SNPs. By expanding the FIDE SNPs, the plans could absorb Medicare-Medicaid plan beneficiaries.

Most states will have to design a pathway from Medicare-Medicaid plans to meaningfully integrated plans.

Also, the sunsetting of the Medicare-Medicaid plan model may require CMS to rethink the role of the MMCO.

The researchers pointed out that the MMCO’s functions extend beyond the Medicare-Medicaid plans. The office should continue to be responsible for overseeing Medicare-Medicaid integration and it is the only office that is dedicated to both programs, as opposed to other oversight bodies that focus on either Medicare or Medicaid.

“As the end of the MMP nears and the future of MMCO is uncertain, it is important to ensure Medicare-Medicaid integration successes are not lost,” the researchers underscored.

They suggested four administrative and regulatory changes that could support integration of Medicare and Medicaid as CMS sunsets the Medicare-Medicaid plans.

First, policymakers should address the role of MMCO and the extent of its authority. MMCO leaders have expressed that they do not have the power to engage more broadly in Medicare-Medicaid integration. But the researchers urged Congress to formalize MMCO’s authority over the Financial Alignment Initiative, dual eligible special needs plan endeavors, and other related programs.

Second, as states are required to sunset their Medicare-Medicaid plans, they should also be required to set up integrated programs.

“States face competing priorities and political pressures that inhibit a shift to an integrated program. Absent a mandate, dual eligible individuals in many states and counties will continue to lack access to an integrated option,” the researchers stated.

States can use dual eligible special needs plan State Medicaid Agency Contract (SMAC). Additionally, they should be required to formulate an integration plan and should receive planning grants and technical assistance, with MMCO oversight.

Third, policymakers should remove the financing and payment barriers to integration. Funds should be fungible between Medicare and Medicaid services and siloes should be disintegrated. States should be allowed to participate in Medicare savings that are a result of integration investments.

Finally, lawmakers and CMS should create training of enrollment support providers so that they can share the value of integration. There should also be incentives for enrolling dual eligibles in meaningfully integrated programs.

“CMS should work with the Administration for Community Living (ACL) and states to ensure the aging and disability network (including SHIPs) is equipped to serve dual eligible individuals, and Congress should ensure sufficient resourcing,” the researchers added.

For payers who are considering entering the dual eligible market during this sunset period, separate research has outlined five factors to keep in mind.

 
 

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STATE NEWS- Copays no longer required for Mississippians on Medicaid

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: The state is dropping copays. Well for members anyway. Docs will get the copays from the state moving forward.

 
 

Clipped from: https://mississippitoday.org/2023/05/02/no-more-copays-mississippians-medicaid/

Mississippians who are insured by Medicaid no longer have to make copayments for health care services, the state’s Division of Medicaid announced.

The policy change, which went into effect May 1, includes copays for prescription medications as well as hospital and doctor’s office visits.

The Medicaid division will keep paying providers for their services, including copays — the only change is that beneficiaries will no longer be responsible, according to communications officer Matt Westerfield.

Copays are a form of cost sharing in health insurance plans. Insurance companies pay a portion of the bill, while the patient is responsible for a certain out-of-pocket amount. 

Harold Miller, CEO of the Center for Healthcare Quality and Payment Reform, said copayments in Medicaid create problems for both policyholders and providers. 

 
 

Copays can discourage people from getting the care they need because they cannot afford it, which can snowball into a worse, even more expensive health care issue, “which means the Medicaid program would end up paying more overall,” Miller said. 

“For example, if an asthmatic child doesn’t get an inhaler because their parents can’t afford the copayment, they could end up in the hospital,” he said. “Sometimes people stretch out medications to reduce the number of refills, and that can cause problems.”

And then providers have to try and collect the copays.

“If the person can’t afford the copayment and the provider sees the patient anyway, the provider just gets paid less, and that can discourage physicians from taking on Medicaid patients,” Miller said. “In theory, the copayment discourages people from getting services they don’t need, but on balance, the problems they create by discouraging necessary care likely outweigh the advantages.”

In a month, Medicaid plans to submit a state plan amendment in pursuit of the change to the Centers for Medicare and Medicaid, which is required when a state plans to revise its policies. If approved, it will be retroactively effective to May 1. The amendment will be posted on the Medicaid agency’s website upon its submission. 

“We are always looking for opportunities to increase access to services while reducing administrative burdens on members and providers,” Westerfield said.

 
 

Republish our articles for free, online or in print, under a Creative Commons license.

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STATE NEWS- Nevada Medicaid gets $2.5 million to expand dental services for the disabled

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: After decades of waiting, I/DD members in Nevada can now get basic dental care. Meanwhile, far-left wing activists want to make sure we don’t remove one single un-eligible Chad-the-otherwise-healthy-27-year-old bartender with an ACA card.

 
 

Clipped from: https://www.kolotv.com/2023/05/02/nevada-medicaid-gets-25-million-expand-dental-services-disabled/

 
 

Those with intellectual and developmental disabilities can now take advantage of six new services(WBNG)

CARSON CITY, Nev. (KOLO) – In a first for Nevada, the state’s Medicaid has received $2.5 million to expand dental services for adults with intellectual and developmental disabilities.

The money comes from the American Rescue Plan Act and a Federal 19 Title Grant.

“Caregivers and people with disabilities face day-to-day challenges with activities that we take for granted,” said Nevada State Dental Officer Dr. Keith Benson. “Simply brushing teeth in the morning can be a monumental challenge for patients and caregivers.”

Many people with intellectual and developmental disabilities are not able to sit for a dental visit without needing sedation or anesthesia. The following services will now be made available:

  • Root canals
  • Preventative Care
  • Multiple doctor’s appointments
  • Fillings
  • Cleaning
  • Sedation

“I have seen stress, effort, and cost place a huge burden not only on patients but also on loved ones and caregivers,” Dr. Benson said. “I applaud the dentists in our state that have stepped up to the challenge to serve this population.”

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STATE NEWS- Tentative deal would raise Medicaid spending in New York

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Providers screeching for a rate increase upon the news of a 7% bump- “Yay!” Big Union Bosses at SEIU with tentacles in the NY Medicaid program- “… not so fast.”

 
 

Clipped from: https://spectrumlocalnews.com/nys/central-ny/ny-state-of-politics/2023/04/27/tentative-deal-would-raise-medicaid-spending-for-hospitals–nursing-homes

Hospitals and nursing homes in New York could receive a higher reimbursement rate under a tentative agreement in the state budget. 

But a broader deal for a state spending plan was not finalized on Thursday, and state lawmakers have left Albany for the next several days as issues addressing climate change are yet to be locked down. 

A source Thursday said Medicaid reimbursement rates will increase for hospitals by 7.5%. For nursing homes, the rate will increase by 6.5%. 

The health care workers union 1199SEIU called the tentative plan not nearly enough. 

“Providers serving the most vulnerable New Yorkers are emerging from the pandemic considerably weakened by soaring costs, the end of dedicated Federal funding and a decade of flat Medicaid rates,” said the union’s president George Gresham. 

Health care networks have pointed to financial complications in the wake of the COVID-19 pandemic and had sought reimbursement rates of 10% in the budget. Gov. Kath Hochul’s initial proposal called for 5% increases. 

New York’s Medicaid program is the second largest in the country and health care spending is the biggest item in the state budget. 

Even as framework deals are reached on issues like the child tax credit, other provisions remained unresolved. 

Democrats in the state Assembly met for several hours on Thursday in a closed-door meeting and wrestled over policies addressing climate change including measures for all-electric construction. A proposal to align the state’s utility regulations with the goals of a sweeping climate law is off the table, a source said. 

Hochul on Tuesday told reporters she was optimistic for a deal before the week was over. But Assembly Democrats are not expected back until Sunday to discuss budget details.  

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FWA- California physician pays $24M to settle Medicare, Medicaid overbilling allegations

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Aronowitz, et al stole $24M of your tax dollars using an upcoding scheme and re-using single use skin grafts.

 
 

Clipped from: https://www.beckershospitalreview.com/legal-regulatory-issues/california-physician-pays-24m-to-settle-medicare-medicaid-overbilling-allegations.html

A California plastic surgeon will pay $23.9 million to settle allegations his practice submitted false claims to Medicare and Medicaid. 

According to an April 28 news release from the Justice Department, the settlement resolves allegations that Joel Aronowitz, MD, his son Daniel Aronowitz, and Dr. Aronowitz’s medical practices and billing company submitted false claims to government payers. 

The Justice Department alleged Dr. Aronowitz manipulated billing codes for skin graft procedures to maximize reimbursement. The department also alleges Dr. Aronowitz improperly disposed of single-use skin grafts and reused portions for later procedures. The improper disposal resulted in “thousands of instances” of double-billing to Medicare and Medicaid, the department alleges. 

As part of the settlement, Dr. Aronowitz and his practice are barred from billing Medicare or Medicaid for 15 years. Daniel Aronowitz is excluded for three years. 

The state of California paid a portion of the alleged false Medicaid claims and will receive nearly $500,000 in the settlement. 

Subscribe to the following topics: californiahealthcare fraudfalse claims actmedicare fraudmedicaid fraud

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FWA (TX)- Investigation by Paxton’s Medicaid Fraud Control Unit Leads to 60-Month Prison Sentence for Home Health Care Fraudster and Over $3 Million in Restitution

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Joyce Agu stole $3M of your tax dollars by paying other providers to lie and say her clients could get home health services.

 
 

 
 

Clipped from: https://www.texasattorneygeneral.gov/news/releases/investigation-paxtons-medicaid-fraud-control-unit-leads-60-month-prison-sentence-home-health-care

Attorney General Paxton’s Medicaid Fraud Control Unit investigated and helped secure the conviction and sentencing of Joyce Agu, a Sugar Land resident, to 60 months in federal prison, followed by three years of supervised release. Agu was convicted for conspiracy to pay and receive kickbacks and was also ordered to pay $3,068,952 in restitution.  

“Fraudulent schemes like the one perpetrated by Ms. Agu undermine our health care system and maliciously exploit funding that comes from hardworking taxpayers,” said Attorney General Paxton. “We will continue to tirelessly pursue and bring to justice individuals who steal money from public programs.” 

Agu was convicted of paying other individuals to certify that her clients were able to receive home health services in order to then bill Medicare. This was done despite the fact that the individuals did not qualify for the services, or even receive services at all in some cases.  

The investigation was conducted by Sergeant Dino Vergara, Investigative Auditor Wanda Guess, and Captain Rick McCollum of Attorney General Paxton’s Medicaid Fraud Control Unit, in cooperation with the Department of Health and Human Services’ Office of Inspector General and the FBI. Assistant U.S. Attorneys Rodolfo Ramirez and Grace Murphy prosecuted the case. 

In the last fiscal year, Attorney General Paxton’s Medicaid Fraud Control Unit recovered over $236 million in taxpayer funds. If you suspect Medicaid fraud or abuse, or patient neglect, please report it by visiting the Texas Attorney General’s website. 

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FWA (TX)- MCO overpaid durable medical equipment vendors by more than $18,000

 
 

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: TX HHS says BCBS of TX can do better next time after finding $18k of DME improper payments it let slip through.

 
 

Clipped from: https://oig.hhs.texas.gov/about-us/news/mco-overpaid-durable-medical-equipment-vendors-more-18000

The OIG recently audited Blue Cross and Blue Shield of Texas (BCBS), finding the managed care organization lacked adequate controls to detect fraudulent claims for durable medical equipment (DME).  

According to the report, BCBS did perform some oversight activities for DME claims, including complying with pricing, timing and claim payment timeliness requirements. However, not all requirements were met before issuing reimbursements to vendors. Specifically, BCBS did not consistently: 

  • Comply with Texas Medicaid Provider Procedures Manual (TMPPM) benefit limits in accordance with the Uniform Managed Care Contract and the Uniform Managed Care Manual.
  • Conduct oversight activities to ensure DME was authorized, medically necessary, or received by members.
  • Validate or accurately price miscellaneous DME claims.

BCBS stated that its policy was to follow TMPPM requirements in processing DME reimbursements. Still, auditors found that the MCO had not provided a subcontractor with information on properly processing DME claims. The lack of suitable oversight resulted in 39 inappropriately processed claims totaling more than $18,105.57. 

In response to the audit, BCBS stated that it has already taken steps to improve its controls and prevent overpayments, including implementing a new system to verify the delivery of DME items. The MCO also updated policies to ensure reasonable prices and committed to reviewing and investigating potential fraud cases more thoroughly.

These efforts align with the OIG’s recommendations, including that BCBS: 

  • Ensure that its claims processing subcontractor implements edits to ensure claims are reimbursed according to required benefit limits and exclusions for: 

 
 

  • Total rental cost limits.
  • Allowed DME amounts. 
  • Multiple claims for the same DME to the same member in one calendar month. 
  • Duplicate claims. 
  • Develop and implement oversight processes to verify its claims processing subcontractor identifies and denies claims for related procedure codes in accordance with benefit limit and exclusion requirements.
  • Develop oversight processes or provide DME providers with guidance for (a) prior authorization requirements, (b) maintaining a physician’s order to demonstrate the member’s need for the DME, and (c) delivery confirmation demonstrating the member received the DME. 
  • Develop and implement a process to verify miscellaneous DME claims are paid in accordance with BCBS requirements.

Auditors also found that BCBS should repay the state of Texas $18,105 for processed claims that did not meet the TMPPM requirements. 

 
 

 
 

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FWA (AR)- Hospital agrees to pay $1.1 million in Medicaid fraud settlement

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: The conclusion of the Brian Hyatt story- turns out his egregious upcoding for BH services added up to about $1.1M of your tax dollars.

 
 

Clipped from: https://www.5newsonline.com/article/news/crime/medicaid-fraud-settlement-dr-hyatt/527-669584d9-f4d2-4ae5-bc61-2dbfbe677667

SPRINGDALE, Arkansas — Northwest Health has reached a settlement with the Arkansas Attorney General’s office after an investigation found evidence claiming Dr. Brian Hyatt, former head of the behavioral unit in Springdale, had committed extensive Medicaid fraud.

Dr. Hyatt stepped down from his role as chair of the Arkansas State Medical Board after he was accused in an affidavit by investigators with the AG’s office.

Hyatt, formerly the chairman of the state medical board, said in an email on March 1, 2023, that he would like to “step aside” as chairman and “move to a non-executive committee, voting member… until standing issues resolve.”

Dr. Hyatt was appointed by former governor Asa Hutchinson in 2019, according to his practice’s website bio. 

In the $1.1 million settlement, Northwest denies it knew it violated the Arkansas False Claims Act. The hospital terminated its contract with Hyatt in May 2022 after lawsuits were filed against him and the hospital.

The payments cover nearly 250 “concerning” Medicaid claims made by Hyatt during his tenure at the Northwest Behavioral Unit in Springdale.

Alleged Medicaid fraud

The Office of Medicaid Inspector General (OMIG) sent a letter to Dr. Hyatt on Feb. 24, 2023, stating that allegations of Medicaid fraud that were made against him were deemed credible. OMIG said that Medicaid services performed by Dr. Hyatt were suspended.

According to the investigation, Hyatt had billed more Medicaid recipients using the highest code than any other doctor had billed for all of their patients in the state.

The investigation notes that between Jan. 1, 2019, and May 2022, 99.95% of Dr. Hyatt’s claims for Medicaid were billed under the highest code, which receives the most amount of Medicaid payment from the state.

For reference, the document states that between that same timeframe, on average nationally, only about 21% of Medicaid billing was for the highest code.

The Attorney General’s office says that employees in the unit were told by Hyatt to always bill the highest code with each patient.

While going over months of surveillance video of the behavioral unit while Hyatt was the director there, the investigator said that after reviewing hundreds of hours and several days of footage, at no point did they see Dr. Hyatt enter a patient’s room or have contact with a patient, only him walk up and down the hall.

Dr. Hyatt also is facing nearly a dozen lawsuits in civil court claiming false imprisonment and other accusations relating to allegedly keeping them in the behavior unit as long as possible in order to obtain more Medicaid funding.

Lawsuits alleging false imprisonment

Dr. Hyatt became the medical director of the behavior unit at Northwest Medical Center in Springdale from Jan. 2018 until May 2022 when his contract was “abruptly terminated by the hospital,” the investigation states.

During that time, a lawsuit was filed against Dr. Hyatt and the hospital, claiming that a woman who had accidentally overdosed on Tylenol and was subsequently kept in the unit against her will.

The woman suing Dr. Hyatt said she’d expressed to employees that she wanted to leave but was told that if she tried to leave they would take her to court to get her to stay longer because “the judge always sided with Dr. Hyatt.”

The lawsuit alleges that a judge had issued a court order to require Northwest Medical to release the woman. 

Dr. Hyatt reportedly had gone to the woman’s room that day and said “he and Northwest would see her lawyer in court and that when she lost in court she would never be able to get a job,” the lawsuit alleges.

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