Category: MM Curator

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EXPANSION- Medicaid agreement in North Carolina closes in on passage

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]: There are a few more hurdles to get through before Expansioners open the champagne, namely: the budgeting for it is in a separate bill (on purpose) that will happen in July, and, oh-yeah- work requirements are in the mix.

 
 

Clipped from: https://www.seattletimes.com/business/medicaid-agreement-in-north-carolina-closes-in-on-passage/

RALEIGH, N.C. (AP) — The details of a deal reached by North Carolina legislative Republicans to expand Medicaid to hundreds of thousands of low-income adults received overwhelming initial approval from the state Senate on Tuesday.

The 43-2 vote on formal legislation comes less than two weeks after House and Senate leaders unveiled an agreement that could cover 600,000 people who make too much to qualify for conventional Medicaid but not enough to obtain highly subsidized private insurance.

North Carolina, currently with 2.9 million enrollees in traditional Medicaid coverage, is one of 11 states that haven’t yet adopted expansion.

“We have been talking about this for a long time,” said Sen. Joyce Krawiec, a Forsyth County Republican. She shepherded the bill on the Senate floor Tuesday after opposing the expansion idea for many years.

Republicans in charge of the legislature were skeptical over the past decade about expansion, made available through the 2010 Affordable Care Act. But the tide changed over the past year as lawmakers became more comfortable with the idea. They also were tempted with the receipt of an additional $1.8 billion over two years from Congress if North Carolina signed on now. Many state officials want to earmark a great deal of that money for mental health services statewide.

An agreement reached after weeks of negotiations earlier this month also included provisions that eased or eliminated certain “certificate of need” laws that require health regulators to sign off on plans for medical entities to build locations or purchase equipment. The Senate demanded such changes as a way to increase the supply of services for the larger covered population.

The measure must pass the Senate a second time, probably on Wednesday, before it goes to the House for likely final action by the General Assembly. Democratic Gov. Roy Cooper, a longtime expansion advocate, would be asked to sign the bill into law.

While expressing support for the legislature’s agreement, Cooper is unhappy with language in the bill that delays enactment of expansion until a separate state budget bill is enacted into law. That’s likely to happen in June or July.

Republicans also now express confidence that the state’s share of medical expenses for the expansion recipients will remain at 10% The state’s hospitals will cover that share through assessments they will pay.

“For a long time, we worried about the financial impact that Medicaid expansion would have on North Carolina. We weren’t sure. But the federal government has continued to make it better and better for us,” Krawiec said.

Democratic Sen. Gladys Robinson of Guilford County pushed for expansion in years when Republican were cool to the idea. She said that while “there are some pieces that that I may not agree with, but I support getting this done.”

“It’s a little late,” Robinson said, “but we’ll take it.”

Robinson and others who spoke said expansion would benefit the working poor, many of whom work for small businesses but whose owners can’t afford to provide insurance.

Hospitals, particularly in rural areas, also will benefit from other bill language that directs the state to enter a federal program by which hospitals would receive additional Medicaid reimbursement funds. The state would seek at least $3.2 billion in hospital reimbursements during the next fiscal year thanks to the program, and that’s before expansion enrollees are considered, according to the legislature’s fiscal staff.

The measure also would beef up efforts to help expansion recipients land employment that will allow them to leave Medicaid coverage. It directs Cooper’s administration to attempt to negotiate with federal regulators to add a work requirement as a condition of participation in the expansion program to be called NC Health Works.

GARY D. ROBERTSON

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REFORM- Republicans take aim at Medicaid as budget talks heat up

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 annual pretending that we will ever cut Medicaid dons its 2023 costume.

 
 

Clipped from: https://www.politico.com/news/2023/03/08/house-democrats-republicans-medicaid-00086136

Republican House and Senate leadership have been adamant that they will not cut Social Security and Medicare, but have said less about Medicaid.

 
 

“No one’s interested in doing anything other than saving it to make it more solvent for those that might need it down the road,” Sen. Mike Braun (R-Ind.) told POLITICO. “If you want to save [Medicaid] for future generations, it’s never too early to look at how to do that.”

Biden, who is expected to release his budget on Thursday, has spent much of the year castigating Republicans for proposals to cut Medicare, Social Security, Medicaid and the Affordable Care Act part of a broader effort to paint the GOP as a threat to popular health programs. Though Democrats, who control the Senate, will almost certainly reject big cuts to Medicaid, Republicans’ desire to rein in federal spending portends a drawn out political fight over a program that now insures more than one-in-four Americans.

Republican House and Senate leadership have been adamant that they will not cut those two entitlement programs, but have said less about Medicaid, which insures more than 90 million Americans. That number swelled during the Covid-19 pandemic, when states were barred from removing people who were no longer eligible.

Asked if assurances by GOP leaders that Medicare and Social Security are off the table have put more pressure on lawmakers to find savings in Medicaid, Rep. Michael Burgess (R-Texas) quipped: “It doesn’t take much imagination to figure that out.”

Some Republicans want to revive a 2017 plan to phase out the enhanced federal match for Medicaid and cap spending for the program — an approach the Congressional Budget Office estimated would save $880 billion over 10 years and increase the number of uninsured people by 21 million.

“If you remember back to the American Health Care Act, we proposed that we make some significant changes to Medicaid. I think you’re gonna find that some of those same ideas are going to be revisited,” said Rep. Buddy Carter (R-Ga.), a member of the House Budget Committee and the conservative Republican Study Committee, a group now working on its own budget proposal to pitch to GOP leadership.

Carter added that there is also interest in the caucus in abolishing Obamacare’s Medicaid expansion, arguing that the majority of states that have opted to expand the program over the last decade might have “buyer’s remorse.”

“Medicaid was always intended for the aged, blind and disabled — for the least in our society, who need help the most,” he said. “Trying to get back to that would probably be beneficial.”

Carter and many other Republicans are also pushing for Medicaid work requirements, though the one state that implemented them saw thousands of people who should have qualified lose coverage.

“For the people who are on traditional Medicaid — the pregnant, children and disabled — there’s no sense in talking about work requirements,” Burgess said. “But for the expansion population, able-bodied adults who were wrapped in under the Affordable Care Act, yeah, that has to be part of the discussion.”

Other Republicans want to make narrower reforms. Rep. Brett Guthrie (R-Ky.), who chairs the Energy and Commerce Committee’s Health Subcommittee, is looking at changes to value-based payments in Medicaid so that states aren’t “on the hook for treatments that don’t work.” Still others are weighing potential changes to areas within Medicaid, including provider taxes and how to handle coverage for people who are eligible for both Medicare and Medicaid.

The GOP members are spurred on by outside conservative groups like the Paragon Institute, which has been holding monthly briefings for Capitol Hill aides and backchanneling with members.

“If you look at what’s driving the debt, it’s federal health programs,” Brian Blase, the president of Paragon, who worked at the White House’s National Economic Council under the Trump administration, told POLITICO. “Either Congress will reform federal health programs or there will be a massive tax increase on the middle class.”

Democrats, for their part, are working to make any proposal to cut Medicaid as politically risky for Republicans as threats to Medicare.

“I worry that my Republican colleagues have, I guess, heard from the public about their desire to cut Social Security and Medicare [and] are looking elsewhere, and obviously poor people have very little representation in Congress, so that’s an easy target,” said Sen. Bernie Sanders (I-Vt.), who chairs the Health, Education, Labor and Pensions committee.

Democrats hoping to shield Medicaid in the upcoming budget negotiations are emphasizing how many red states have voted to expand the program since Republicans last took a run at it in 2017. They’re also stressing that the people covered by Medicaid aren’t solely low-income parents and children.

“Right now at least 50 percent of Medicaid goes to seniors, and a lot of that is for nursing home care,” Rep. Frank Pallone (D-N.J.), the top Democrat on the Energy and Commerce Committee, told reporters. “People don’t realize that Medicaid is the ultimate payer for nursing home care once you run out of money or once your Medicare runs out.”

In a speech in late February, President Joe Biden excoriated Republicans for pushing deep cuts to Medicaid, arguing that doing so would threaten the finances of rural hospitals that are barely able to keep their doors open today.

“Many places throughout the Midwest, you have to drive 30, 40 miles to get to a hospital. By that time, you’re dead,” he said. “Entire communities depend on these hospitals. Not getting Medicaid would shut many of them down.”

Two people familiar with White House plans tell POLITICO that Biden is expected to include a federal expansion of Medicaid in the remaining holdout states in the budget he will submit to Congress later this week.

Adam Cancryn contributed to this report.

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STATE NEWS (MS)- Medicaid to provide less than expected for Mississippi hospitals

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 commercial pays way less than the BlackBox of hospital payments would have us think. All the wailing over how low Medicaid rates are may be just a tad dramatic. Or perhaps a smidgeon.

 
 

Clipped from: https://mississippitoday.org/2023/03/09/mississippi-hospitals-medicaid-payments/

Mississippi hospitals, many on the precipice of closure, will be getting much-needed additional money this year. 

But the amount they receive might be much lower than expected. 

The Mississippi Division of Medicaid proposed changing the way it calculates some additional funding hospitals in Mississippi receive called “supplemental payments.” One of the funds, called the Mississippi Hospital Access Program payments, gives hospitals the difference between what Medicaid actually paid for services rendered and what Medicare would have paid for similar claims, offsetting losses incurred by standard Medicaid payments being too low.

But on Feb. 15, the Mississippi Division of Medicaid submitted a request to the Centers for Medicare and Medicaid Services to change that model to pay hospitals the difference between Medicaid rates and what an average commercial plan’s rate would have paid.

The goal was to generate more money for hospitals. 

Tim Moore, president of the Mississippi Hospital Association, said the original estimate hospitals received from the Division of Medicaid for supplemental MHAP-generated funds after the change was around $450 million.

The most recent calculation, however, is $40.2 million. 

“The preliminary estimates from last fall were subject to change based on Mississippi-specific data, and those estimates were not submitted to CMS,” said Matt Westerfield, communications officer at the Division of Medicaid.

Currently, Mississippi hospitals have two sources of funds called “supplemental payments” — the MHAP and disproportionate share hospital, or DSH, payments. These funds are a combination of federal and state money.

Since it was created in 2015, MHAP has yielded half a billion dollars to Mississippi hospitals, or about 8.3% of Medicaid spending in the state. 

The problem with using average commercial reimbursement rates for a new calculation for MHAP payments is that Mississippi’s insurance reimbursement rates are so low, said Moore. 

And that’s not all: Because of a complex rule about hospital funding limits, hospitals will receive $95 million less in the second type of supplemental payment (DSH) this year.

For hospitals that mostly serve patients from low-income backgrounds, DSH payments help hospitals recoup the cost of providing care to patients who cannot afford to pay. The total amount for Mississippi hospitals averages around $230 million each year, according to Moore. 

“It’s a swap, in order to maximize dollars,” Moore said. “There’s not one lever you pull that doesn’t affect anything else.”

So, after accounting for the decrease in DSH funds, additional MHAP payments and one-time pandemic emergency relief funds, hospitals could net a total of $96 million in extra funds. 

Lawmakers are also currently considering a bill that would give an additional $80 million in federal COVID-19 relief funds to hospitals. 

Earlier this year, the Association projected that Mississippi hospitals would need a total of $230 million in additional funding to fill their financial gaps and sustain operations. Even with the grants, Mississippi hospitals are about $60 million short. 

But the money’s got to come from somewhere, Moore said. Over a third of rural hospitals are on the brink of closure and need desperate help.

“Hopefully, the Legislature will increase the $80 million to a higher number,” Moore said. 

Lt. Gov. Delbert Hosemann and Speaker Philip Gunn did not respond to questions about whether lawmakers would consider appropriating more money to hospitals by Wednesday afternoon.

And even if hospitals do get enough from additional supplemental payments, it’s possible that small, rural hospitals most in need of help will get the least funding. 

Under the new proposed MHAP supplemental payment model, the payments are adjusted based on average commercial insurance rates. But that’s not a statewide average — that’s an average for each hospital. 

So, a hospital’s extra MHAP payment will depend on how much it gets reimbursed on average by commercial insurers. And according to Mike Chaney, state insurance commissioner, that isn’t always equal.

“There are some hospitals, especially in the rural part of the state … that do not get paid on the same level that urban hospitals get paid for health care,” he said. 

Currently, Medicaid is waiting on CMS approval for the change to MHAP payments.

“Medicaid has pushed for a rapid process, if there is such a thing,” Moore said. “They’ve impressed upon CMS the urgency of getting this done.”

But he stressed that if Medicaid was expanded, Mississippi’s hospitals wouldn’t be in this state. 

“It doesn’t fix all the problems, and we’ve never said it would … but our hospitals wouldn’t be in as big a deficit as they are today,” he said. “The hole has gotten bigger and bigger and bigger. And now you’ve got to have money to fill the hole.”

.

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MCOs (NM)- State was prepared to notify providers on Medicaid contracts before canceled procurement

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]: They even had the winner’s awards letters ready to go. Oh yeah, also the “sorry you lost” letter was ready to go, too.

 
 

Clipped from: https://www.abqjournal.com/2581850/new-mexico-medicaid-providers-canceled-procurement.html

SANTA FE – In mid-January, state Human Services Department officials had letters ready to go notifying four of the five bidders for massive contracts to run New Mexico’s Medicaid program that they had been selected.

But those letters were never sent and, just over a week later, the agency announced it was taking the unusual step of canceling the procurement process and starting over, according to records obtained by the Journal.

The abrupt decision, which was made after Gov. Michelle Lujan Grisham expressed concern about a possible disruption of services if a current Medicaid managed care organization was not issued a new contract, has rattled the Roundhouse and prompted some lawmakers to demand more information.

Legislators earlier this month asked for the full scores of the initial Medicaid contract bidders, after a Journal report on the evaluations, while also questioning top Human Services Department officials about the decision to cancel the process.

“Knowing what those scoring sheets look like, I think that would be useful to us while we’re still here at the Legislature,” said Sen. William Sharer, R-Farmington, during a Senate Finance Committee meeting earlier this month.

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In response, Human Services acting Secretary Kari Armijo said the agency was in the process of hiring an outside Medicaid expert and should have recommendations about the new contract structure within the next 45 days.

In the time since Armijo addressed legislators, the state has contracted with an outside expert who will make recommendations regarding the procurement process and timeline, HSD spokeswoman Marina Piña said this week.

In her discussion with lawmakers, Armijo also said she could not discuss specific evaluations, but vowed to provide senators with the score sheets in question.

“There were concerns expressed about low scores in certain critical areas almost across the board on all bidders in certain key areas that are very important to the Medicaid program,” Armijo said.

She also said health insurers need to bring their “A game” in their follow-up bids.

However, she did not tell lawmakers just how close the department was to readying the announcement of the new contract recipients under the state’s Medicaid program, which were set to take effect next year as part of a rebranded program known as Turquoise Care.

The new documents obtained by the Journal show the state readied intent letters announcing the awarding of contracts for the health care insurers vying for Turquoise Care contracts less than two weeks before canceling the procurement.

The documents, which include email communications involving Armijo, former HSD Secretary David Scrase and former Medicaid Director Nicole Comeaux, also show the direct involvement of the Governor’s Office in the abrupt decision to not forge ahead with the prepared letters.

Specifically, Armijo sent a Jan. 29 email to Teresa Casados, the chief operating officer in the Governor’s Office, that references a letter that would notify managed care organizations of the state’s intent to cancel the contract process and was drafted at the “direction” of Casados two days earlier.

The email also suggested Charles Canada, HSD’s procurement manager, had not yet been notified of the decision.

Procurement scrapped

The state decided to cancel the procurement process the same day Scrase publicly announced his retirement, but did not announce the decision until three days later — on Jan. 30.

The decision, according to Piña, in part came from the low scores the five bidders received.

Blue Cross and Blue Shield of New Mexico, one of four providers on the state’s current Medicaid contract, scored the highest with 1,083.5 points out of a maximum of 1,815 points.

Western Sky Community Care, a subsidiary of St. Louis-based Centene Corp. and also a current managed care organization, was the lone provider not recommended for a new contract under the previous procurement, scoring a total of 1,022 points.

After the scores were shared, the governor and top staffers in her office “shared concerns” with top HSD officials about a possible disruption of services, a Lujan Grisham spokeswoman told the Journal last month.

But the Human Services Department previously said the reason for halting the procurement process was due to the high-level departures of Scrase and Comeaux, and in order to give their successors the ability to help guide the contract process.

Comeaux has declined to comment on the issue, while Scrase said last month he did not have much insight into the decision.

Scores were low

New Mexico currently pays about $935 million in state funds to run its Medicaid program, and roughly $8 billion total when federal matching funds are included.

While the Human Services Department has withheld the submitted bids, describing them as “confidential,” the agency has disclosed the final scores of the five health insurers seeking to land Medicaid contracts.

Those scores show the four highest-ranked bidders were Presbyterian Health Plan, UnitedHealthcare of New Mexico, Blue Cross and Blue Shield of New Mexico and Molina Healthcare of New Mexico.

Drafted intent letters were written for all four of those insurers, according to records obtained by the Journal.

The records also show a letter had been drafted notifying Western Sky Community Care that it had not been selected for a contract for the new Medicaid program.

While Human Services Department officials have insisted the agency still intends to pick new providers before the end of this year, some lawmakers have floated the possibility of more legislative involvement in future instances when a procurement is canceled.

“I think the Legislature may have the authority to look at the RFPs and say, ‘Here are the top five providers,'” said Sen. George Muñoz, D-Gallup, the Senate Finance Committee’s chairman.

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MCOs (IN)- Centene comes up short on new Indiana Medicaid contract

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 loss stings, but new(ish) CEO London assures shareholders that there is robust lesson-learning happening.

 
 

Clipped from: https://www.bizjournals.com/stlouis/news/2023/03/14/centene-comes-up-short-on-new-indiana-medicaid.html

 
 

Enlarge

Centene’s headquarters in Clayton.

Dilip Vishwanat | SLBJ

Clayton-based Centene Corp. (NYSE: CNC) has lost out on a lucrative contract for a new managed care program in Indiana.

The Indiana Department of Administration recommended on March 1 that negotiations begin with four bidders to provide services so Medicaid recipients over the age of 60 can continue to live in their homes.

Those companies are Anthem Blue Cross and Blue Shield, Humana Healthy Horizons in Indiana, Molina Healthcare of Indiana and UnitedHealthcare Community Plan. A wholly-owned subsidiary of Clayton-based Centene, Managed Health Services, was not chosen, along with CareSource Indiana and MDWise Inc.

The estimated value for the four-year contracts is $3.8 billion for each of the companies chosen through a request for proposal, which the state of Indiana issued in February 2022. Managed Health Services ranked fifth in the final RFP score to provide long-term services and supports, referred to as LTSS.

The outcome is the latest in a series of ups and downs in the post-CEO Michael Neidorff era. In late December, Centene won back two big-ticket Medicaid contracts in California after filing appeals. A California state agency scrapped an RFP and issued direct contacts with Centene’s subsidiary to serve Medicaid enrollees in Los Angeles County – with a 50% subcontract to Molina Healthcare of California – as well as in Sacramento and eight other counties.

A few weeks earlier, the U.S. Department of Defense on Thursday bypassed Centene in awarding $136 billion in contracts for the health insurance provided to active-duty military members, a blow to Centene, which long held some of the work.

Centene’s current CEO, Sarah London, was asked Tuesday at the Barclays Global Healthcare Conference about the RFP pipeline this year.

“The recent Indiana LTSS result was certainly not what we were looking for,” said London. “But I will say that the organization across all lines of business has an increased discipline around looking at where things don’t always go the way we want them to and pulling out valuable lessons learned.”


Enlarge

Centene CEO Sarah London

Centene Corp.

The new program, Indiana Pathways for Aging, is scheduled to launch in the summer of 2024, according to a spokesperson for the Indiana Family and Social Services Administration.

Managed Health Services is a managed care entity that has operated in Indiana for about 25 years through the Hoosier Healthwise and Hoosier Care Connect Medicaid programs and the Healthy Indiana Medicaid alternative program. MHS also offers a Medicare Advantage plan and health plans through the Affordable Care Act marketplace in Indiana.

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PHE- How Aetna is using CVS stores to warn members about Medicaid redeterminations

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]: CVS is playing reminders-to-do-your-Medicaid-paperwork messages in the stores. Not kidding.

 
 

Clipped from: https://www.beckerspayer.com/payer/how-aetna-is-using-cvs-stores-to-warn-members-about-medicaid-redeterminations.html

Aetna is leveraging its parent company’s retail stores to let Medicaid members know they may need to renew their coverage. 

Kelly Munson, president of Aetna Medicaid, a CVS Health company, told Becker’s CVS retail stores have a chance to reach all Medicaid members when they walk into a store, regardless of if they are members of Aetna or another managed care plan. 

“Regardless of payer, CVS can be supportive of all the Medicaid members that are walking in the door,” Ms. Munson said. “We have messaging in the stores that plays over the sound system, videos that remind members they need to be looking for redeterminations, and we have QR codes they can scan so they can know and understand what their next move is.” 

Up to 18 million people nationwide could lose their Medicaid coverage beginning April 1, according to estimates from the Robert Wood Johnson Foundation. Some Medicaid members will lose coverage because they make too much income to qualify for the program, while others may be dropped for administrative reasons. 

Read more about how Aetna is reaching members ahead of redeterminationshere.

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REFORM- How Medicaid Managed Care Orgs Can Better Invest in SDOH Interventions

 
 

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]: “Researchers” are telling us all how MCOs can sell bonds and literally become banks.

 
 

Clipped from: https://healthpayerintelligence.com/news/how-medicaid-managed-care-orgs-can-better-invest-in-sdoh-interventions

Jointly issuing financial bonds would allow Medicaid managed care organizations to receive upfront funding from investors that can be used to advance social determinants of health interventions.

 
 

Source: Getty Images

 
 

By Victoria Bailey

March 10, 2023 – Medicaid managed care organizations can leverage financial bonds to help increase funds for social determinants of health interventions and avoid underinvesting, according to research published in Health Affairs.

Social determinants of health, including food insecurity, transportation barriers, and housing instability, can impact health equity and lead to avoidable health outcomes and spending. Interventions to address these factors typically require significant upfront funding, with benefits occurring down the line in the form of cost savings.

Medicaid managed care organizations experience enrollment and eligibility changes, which may dissuade them from investing in interventions as they are not guaranteed a return on investment. An organization investing in something and not reaping the full return as cost savings is known as the wrong pocket problem.

If a Medicaid managed care organization makes a year-long investment in a social determinants of health intervention and then experiences enrollment losses, its return on investment would not be proportional to its initial investment.

Researchers have proposed a potential solution to the wrong pocket problem: a financial bond, which they refer to as a social drivers of health (SDH) bond. Multiple Medicaid managed care organizations would issue and administer the proposed SDH bond jointly. Individual investors would purchase the bond, expecting a future return, and the money would go toward funding social determinants of health interventions.

After providing upfront funding for the interventions, bondholders would receive regular interest payments at intervals dictated by the bond. In addition, investors would receive the face value of the invested amount at the end of the bond’s term. Unlike a standard bond, investors would also see benefits from pursuing investments that target social determinants.

An SDH bond would allow managed care organizations to receive immediate capital to launch interventions for their beneficiaries. Since social determinants of health interventions help improve outcomes and lower costs, organizations will gradually incur funds to pay back the bonds.

The regular payments could be established based on a proportion of the estimated cost savings of an intervention. Since multiple managed care organizations would issue a bond, the share of outstanding bonds to be serviced would adjust over time depending on each organization’s enrollment, helping to avoid the wrong pocket problem.

Involving the capital market in SDH bonds would allow a greater influx of funds than managed care organizations would usually be able to invest, researchers said. Additionally, pooling funds and the ability to invest across multiple interventions reduces the financial risk through diversification.

Since the interventions are funded from one source, beneficiaries can maintain access to the interventions even if they switch plans or managed care organizations, researchers noted. SDH bonds also allow for potential public-private partnerships to address interventions that may not have a sizeable financial return but impact health equity.

To see the potential benefits of SDH bonds, managed care organizations must consider the number of organizations participating and the possibility of risk-sharing when structuring their bond.

Managed care organizations may face challenges when coordinating with state Medicaid agencies. One issue will be whether SDH bonds will be incorporated into the regular managed care organization procurement cycle, according to researchers. Other state policies, such as the medical loss ratio and premium rate-setting policies, must also be considered when designing the bond.

Organizations may experience difficulties tracking which beneficiaries receive the interventions as they do not generally have procedure codes. Accurate data will depend on the quality of reporting from community-based organizations and their ability to transmit timely data to managed care organizations.

Managed care entities must also consider which interventions to invest in and which community-based organizations should provide them. Researchers suggested issuing requests for proposals from community-based organizations in each state.

Although researchers applied the hypothetical bond to Medicaid managed care organizations, other payers, such as Medicare, could potentially use it.

“The SDH bond is an innovative financial instrument that can help address the wrong-pocket problem and encourage managed care organizations to invest in SDH interventions,” researchers concluded. “Taking this idea from theory to reality will require stakeholder engagement, careful review of the literature, and complex modeling to optimize the structure of the bond.”

 
 

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FWA (MO)- Moberly doctor pleads guilty to defrauding Medicare, 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]: Justin LaMonda and his dad worked together to steal from Medicare and Medicaid. After Justin had already been kicked out of the Medicare program.

 
 

Clipped from: https://www.komu.com/news/midmissourinews/moberly-doctor-pleads-guilty-to-defrauding-medicare-medicaid/article_bd28d834-c2b5-11ed-8e12-7fc73c512666.html

A doctor from Moberly plead guilty Tuesday to federal charges of making false statements related to health care matters, according to a release from the office of the U.S. Attorney for the Eastern District of Missouri.

Dr. Justin G. LaMonda, 41, admitted to using his father’s name to bill Medicare and Medicaid for medical services, according to the release.

In his plea, LaMonda said he and his father mutually agreed to falsely bill Medicare and Missouri Medicaid for services performed by LaMonda as if they were performed by his father, who is also a doctor. 

LaMonda’s medical license was previously suspended for 30 days in 2017 after he was accused of engaging in sexual activity with his office manager. He then prescribed her controlled substances “without sufficient examination,” the plea says.

In 2018, a Medicare administrative contractor revoked his Medicare privileges after determining he submitted reimbursement claims for services performed when he was suspended. In 2019, his Medicare provider number was terminated.

When payments were received for services performed by LaMonda, his father would transfer the funds back to him, the plea agreement said. LaMonda admitted to causing total losses of $537,322 to Medicare and Missouri Medicaid.

LaMonda’s sentencing is set for July 26. He faces up to five years in prison, a fine of $250,000 or both.

To report an error or typo, email news@komu.com.

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FWA (MA) -Lab charged with Medicaid fraud

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]: Rita Ausiejus stole $400k from your W-2 using Medicaid claims for un-allowable urine tests for drug treatment.

 
 

Clipped from: https://www.bostonherald.com/2023/03/12/ticker-mass-jobs-back-to-pre-pandemic-levels-lab-charged-with-medicaid-fraud/

 
 

Lab charged with Medicaid fraud

A clinical laboratory and its owner have been accused of submitting over $400,000 in Medicaid claims for unauthorized urine drug tests, the attorney general’s office in Massachusetts said Friday.

The residential sobriety tests were medically unnecessary, the office said in a news release. Laboratories may not bill Medicaid for them.

The Burlington-based Solid Diagnostics, Inc. and its owner were indicted last month by a statewide grand jury on two counts each of Medicaid false claims, false claims and larceny over $1,200.

The lab and owner are scheduled to be arraigned in Middlesex Superior Court on March 21. It wasn’t immediately known if they had attorneys.

The attorney general’s office said last year, one of its Medicaid Fraud Division investigations resulted in charges against several clinical laboratories, their owners, marketing companies, and a doctor in connection with Medicaid fraud, money laundering and kickbacks involving over $2 million in urine drug tests.

 
 

https://www.lowellsun.com/2023/03/13/burlington-lab-and-acton-owner-accused-of-drug-test-fraud/

 
 

 
 

BOSTON — A clinical laboratory in Burlington and its Acton owner were recently indicted following allegations of Medicaid fraud involving urine drug tests that led to the submission of more than $400,000 in false claims, according to Attorney General Andrea Joy Campbell.

Campbell announced in a press release on Friday that Solid Diagnostics Inc. and owner Rita Ausiejus were indicted by a grand jury in February on two counts each of Medicaid false claims, Medicaid reverse false claims and larceny over $1,200.

Campbell’s office alleges that Solid Diagnostics and Ausiejus submitted claims to MassHealth for urine drug tests that “were not appropriately ordered by physicians or other authorized prescribers.”

The AG added the urine drug tests were also for residential sobriety monitoring purposes. According to the release, laboratories are not allowed to bill MassHealth for tests performed at sober homes for residential monitoring purposes because such tests are not medically necessary.

By billing MassHealth and its managed care entities for these tests, the defendants allegedly caused over $400,000 in false claims.

Solid Diagnostics and Ausiejus are set to be arraigned in Middlesex Superior Court on March 21.

Attempts by The Sun to reach Solid Diagnostics were unsuccessful.

Campbell stated these charges “are the latest development in the work of the AG’s Office to address kickbacks and false claims among Medicaid providers, particularly independent clinical laboratories.”

According to the AG’s office, in December, an independent clinical laboratory agreed to pay $1.5 million to the MassHealth program to resolve allegations by the AG’s Office that it engaged in an illegal kickback relationship with a New Bedford-based clinical laboratory.

 
 

From <https://www.lowellsun.com/2023/03/13/burlington-lab-and-acton-owner-accused-of-drug-test-fraud/>

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FWA (FL) – Jelly Bean Communications Design and its Manager Settle False Claims Act Liability for Cybersecurity Failures on Florida Medicaid Enrollment Website

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]: I don’t know that I have seen this before- a tech provider has been convicted of not making a website secure enough to meet HIPAA requirements, and will pay $293k.

 
 

Clipped from: https://www.justice.gov/opa/pr/jelly-bean-communications-design-and-its-manager-settle-false-claims-act-liability

Jelly Bean Communications Design LLC (Jelly Bean) and Jeremy Spinks have agreed to pay $293,771 to resolve False Claims Act allegations that they failed to secure personal information on a federally funded Florida children’s health insurance website, which Jelly Bean created, hosted, and maintained.

“Government contractors responsible for handling personal information must ensure that such information is appropriately protected,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “We will use the False Claims Act to hold accountable companies and their management when they knowingly fail to comply with their cybersecurity obligations and put sensitive information at risk.”

The Florida Healthy Kids Corporation (FHKC) is a state-created entity that offers health and dental insurance for Florida children ages five through 18. FHKC receives federal Medicaid funds as well as state funds to provide children’s health insurance programs. On Oct. 31, 2013, FHKC contracted with Jelly Bean for “website design, programming and hosting services.” The agreement required that Jelly Bean provide a fully functional hosting environment that complied with the protections for personal information imposed by the Health Insurance Portability and Accountability Act of 1996, and Jelly Bean agreed to adapt, modify, and create the necessary code on the webserver to support the secure communication of data. Jeremy Spinks, the company’s manager, 50% owner, and sole employee, signed the agreement. Under its contracts with FHKC, between 2013 and 2020, Jelly Bean created, hosted, and maintained the website HealthyKids.org for FHKC, including the online application into which parents and others entered data to apply for state Medicaid insurance coverage for children.

The settlement announced today resolves allegations that from January 1, 2014, through Dec. 14, 2020, contrary to its representations in agreements and invoices, Jelly Bean did not provide secure hosting of applicants’ personal information and instead knowingly failed to properly maintain, patch, and update the software systems underlying HealthyKids.org and its related websites, leaving the site and the data Jelly Bean collected from applicants vulnerable to attack. In or around early December 2020, more than 500,000 applications submitted on HealthyKids.org were revealed to have been hacked, potentially exposing the applicants’ personal identifying information and other data. The United States alleged that Jelly Bean was running multiple outdated and vulnerable applications, including some software that Jelly Bean had not updated or patched since November 2013. In response to this data breach and Jelly Bean’s cybersecurity failures, FHKC shut down the website’s application portal in December 2020.  

“Safeguarding patients’ medical and other personal information is paramount,” said U.S. Attorney Roger Handberg for the Middle District of Florida. “This settlement demonstrates the commitment by my office and our partners to use every available tool to protect Americans’ health care data.”

“Companies have a fundamental responsibility to protect the personal information of their website users. It is unacceptable for an organization to fail to do the due diligence to keep software applications updated and secure and thereby compromise the data of thousands of children,” said Special Agent in Charge Omar Pérez Aybar of the Department of Health and Human Services, Office of Inspector General (HHS-OIG). “HHS-OIG will continue to work with our federal and state partners to ensure that enrollees can rely on their health care providers to safeguard their personal information.”

On Oct. 6, 2021, the Deputy Attorney General announced the Department’s Civil Cyber-Fraud Initiative, which aims to hold accountable entities or individuals that put U.S information or systems at risk by knowingly providing deficient cybersecurity products or services, knowingly misrepresenting their cybersecurity practices or protocols, or knowingly violating obligations to monitor and report cybersecurity incidents and breaches. Information on how to report cyber fraud can be found here.

The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, and the U.S Attorney’s Office for the Middle District of Florida, with assistance from HHS-OIG.

The matter was handled by Trial Attorney Michael Hoffman and Assistant U.S. Attorney Jeremy Bloor.

The claims resolved by the settlement are allegations only. There has been no determination of liability.