Category: MM Curator

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FWA (IL)- Hoffman Estates doctor charged with faking Medicaid, insurance claims

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]: Mona Ghosh stole $1M of your tax dollars using a plain ole’ services not delivered scam. She did not say thank you.

 
 

Clipped from: https://www.dailyherald.com/news/20230314/hoffman-estates-doctor-charged-with-faking-medicaid-insurance-claims

A Hoffman Estates doctor is facing federal fraud charges after prosecutors accused her of bilking Medicaid and private insurers out of nearly $1 million by submitting claims for services that were never provided to patients.

Mona Ghosh, 50, of Inverness, was indicted on more than a dozen charges of health care fraud, prosecutors announced today.

In court papers, Ghosh is accused of knowingly submitting false reimbursement claims for treatment that was never delivered between February 2018 and April 2022 totaling about $796,000.

Ghosh owned and operated Progressive Women’s Healthcare in Hoffman Estates during the time the false claims were submitted, according to court records.

If convicted, she faces up to 10 years in prison.

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FWA- How Medicare and Medicaid fraud became a $100B problem for the U.S.

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 size and absurdity of the fraud used to take from your W-2 is profiled in this story. I would say it’s a great read, but it really does just go to show how little you, the taxpayer, are appreciated for funding all this wonderful fraud.

 
 

Clipped from: https://www.cnbc.com/2023/03/09/how-medicare-and-medicaid-fraud-became-a-100b-problem-for-the-us.html

 
 

watch now

VIDEO9:1409:14

Fraud Inc: How to steal $100 billion from Medicare and Medicaid

CNBC Investigations

A nondescript suite of offices in a bland building tucked in a quiet Miami suburb seemed as good a place as any for a medical supply company to rent some office space.

But this company rented space two floors above a regional office of the U.S. Department of Health and Human Services’ criminal investigative unit. It also tried billing Medicare more than $500,000 for various medical equipment — such as braces, orthotics and wheelchairs — for patients who didn’t exist.

During a routine check by HHS’ Office of Inspector General, which investigates Medicare and Medicaid fraud, special agents in Florida noticed that a local company had recently changed owners and had another address in their building. But that location didn’t have any actual employees. It was no more than a mail drop, a physical location of a shell corporation designed to make it look legitimate on paper, said Omar Pérez Aybar, special agent in charge for Florida.

A deeper look at the company’s billing practices revealed what appeared to be Medicare fraud, Pérez Aybar said.

When agents grilled the new owner, he admitted his name was used on corporate business records to conceal the identity of the real owners. Because the investigation is still ongoing and no arrests have been made, agents provided few details identifying the operation. But Pérez Aybar said it was shuttered last year before Medicare lost any money.

Fraud flourishes

That’s just one of thousands of examples of how Medicare fraud is flourishing — not only in south Florida, but across the country.

Taxpayers are losing more than $100 billion a year to Medicare and Medicaid fraud, according to estimates from the National Health Care Anti-Fraud Association.

“That’s probably a conservative number,” Pérez Aybar said. “When we think about all lines of business in Medicare and Medicaid, that’s probably a drop in the bucket.”

Omar Pérez Aybar, Special Agent In Charge / Office of Inspector General

CNBC

The fraud runs the gamut: billing for unapproved Covid tests, phony billing for wheelchairs, braces and other medical equipment, genetic testing fraud, home health-care billing and a host of other schemes. Investigators say fraudsters have gotten more brazen in recent years — as Washington swiftly doled out trillions of dollars in Covid-19 relief funds and other aid in response to the pandemic.

The proliferation of crime has taxed the inspector general, which has just 450 agents around the country. The amount at stake is staggering: Medicare spends about $901 billion a year on its 65 million beneficiaries, while Medicaid spends $734 billion providing medical coverage to more than 85 million poor and disabled Americans every year, according to the Centers for Medicare and Medicaid Services, which falls under HHS. The inspector general describes the fraud as prevalent and inventive, routinely ensnaring full-time criminals as well as legitimate doctors and health-care professionals gone bad, according to its annual reports.

Ripping off Medicare is ‘easy’

“It’s just so easy. It’s unbelievable,” said one Miami man, who admitted that he used to make a living by stealing from Medicare.

This convicted felon says Medicare and Medicaid fraud is “very easy” to get away with.

CNBC

“You’ll be surprised. For money, they’ll do anything,” he said, asking not to be identified for fear of retribution by people he worked with in the criminal underworld. “It’s always been like that. And people keep on — they get caught, they get out, and they’ll do it all over again.”

He was arrested and charged with running an illegal pill business, according to agents who worked his case. The scheme involved multiple players who were all on the take and got a cut of the windfall from defrauding Medicare, the special agents said.

Describing the scheme, the fraudster said he recruited patients to get a prescription from a doctor that was then filled at a pharmacy and paid for by Medicare. He would then remove the label and “wash” the bottle to make it look new before reselling the pills to a wholesaler, which would sell them back to that pharmacy or another one that was in on the deal, he said. The same pills could be sold and resold multiple times with different phony patients, billing Medicare each time.

It was a lucrative scheme.

‘I had houses, I had cars’

“I was low-profile, nobody knew about me. I had everything. I had houses, I had cars, I had watches,” he said, adding that he routinely raked in millions from health-care fraud for more than a decade.

Eventually, though, someone who knew him was caught and turned him over to law enforcement in exchange for more lenient treatment, he said. He ended up pleading guilty to health care-related fraud and served three years in prison.

Even when the fraudsters get caught — the reward may outweigh the risk.

“I don’t think the government can keep up,” he said. “People keep on. They’re not gonna stop.”

Pérez Aybar said the inspector general is understaffed to handle the never-ending volume of cases. In fiscal year 2021, about 2 cents of every $100 spent by HHS went to oversight and enforcement, according to figures compiled by the inspector general’s office.

Fraud is something Medicare and Medicaid take very seriously, Dara Corrigan, deputy administrator of the Centers for Medicare and Medicaid Services, said in a statement to CNBC.

“We continuously work to safeguard taxpayer dollars and strengthen program integrity in our operations by identifying vulnerabilities in the system,” she said. “CMS uses every tool we have to lower the risk of fraud and abuse in the Medicare and Medicaid programs, and collaboratively works with law enforcement to identify and investigate fraud and abuse.”

Buried treasure

In another scheme, inspector general agents in 2021 found $2.5 million in cash wrapped in plastic tucked inside PVC pipes under the home of Jesus Garces. He is serving a 12½-year sentence after he pleaded guilty that year to one count of conspiracy to commit health-care fraud and wire fraud. Garces was operating a fraudulent Medicare company out of a strip mall, Pérez Aybar said. A government informant recorded Garces on a hidden camera smiling as he counted cash he stole from Medicare, according to investigators and a copy of the video obtained by CNBC.

Federal Agents found millions of dollars stuffed in PVC pipes under the home of a man now in prison for Medicare fraud.

OIG | FBI

“We were shocked to know that there was this amount of cash,” Pérez Aybar said. “I think a lot of us hadn’t necessarily seen that much, but it was how it had been packaged, vacuum sealed in bricks, again, stuffed into PVC pipes. And it really was, for us, an indication of how brazen this [durable medical equipment] fraud is.”

Garces “thought he was a CEO, when in fact he was just a crook,” Pérez Aybar said.

Ricardo Carcas, the special agent who oversaw the Garces case, explained how these schemes typically work.

“When I show up, I see that it is the shell that we typically see in this durable medical equipment fraud scheme,” Carcas said, pointing to the storefront in a Miami strip mall where Garces set up his fraudulent medical device company. “It was empty pretty much — it just had a desk (and) a shelf with maybe three orthotic braces in there. And it was closed during operating hours.”

To prove it was fraudulent, Carcas said he identified the referring doctors who supposedly signed off on patients who were billing their medical equipment to Medicare. None of the patients saw those doctors.

Whack-a-mole

“They purchased a list of patient information,” Pérez Aybar said. “They have doctors that they either are using as part of the scheme, they’re paying kickbacks, or they may purchase a list of doctors’ information as well, and then you start submitting the claims. Once the money gets into the bank account, they have money launderers and mules that they paid to go out and just pull the money out of those accounts.”

Pérez Aybar described battling the fraudsters as “almost like the game of whack-a-mole, where we hit one and another pops up.”

On the ground, agents fighting health-care fraud see a never-ending scenario.

Take the Miami Merchandise Mart, for instance.

The sprawling, aging indoor mall houses low-cost, wholesale retailers along with numerous medical supply businesses set up to bilk the government, according to investigators.

When CNBC visited the mall in December, there were numerous storefronts that were largely empty, but for the names of the medical supply companies that adorned the entrances.

Pérez Aybar described what agents have found at the mall and elsewhere during previous investigations.

“It is Medicare regulations that you have to have a business, especially in this case for durable medical equipment. And so usually what — when we go out, what I will see is just a bit of a shell. It’s an office that’s maybe 12 by 15 feet wide,” he said.

“There’s a desk, perhaps, there’s a bit of a curio with one or two different types of braces. They’ll have the manuals that Medicare requires that — that they’re familiar with. And usually there’s some type of partition if let’s say we’re talking about orthotics because the patient is supposed to come in and actually get fitted.”

Medicare storefronts

Along a corridor in the mall, CNBC found a young woman sitting alone at a desk in a small glass-enclosed store called United Med Supply Market Inc. She said it was a medical supply business and gave us the business card with a phone number for the owner. When a reporter called the number a few minutes later, it rang at the woman’s desk.

Company President Antonio Lantigua was reached by phone several weeks later. When asked why equipment wasn’t visible on site, he said they keep it in other locations.

“We have equipment in other places. We send papers to the company; the company sends equipment to the patients,” Lantigua said.

When pressed for more information, he said, “I don’t know why you are calling me” and hung up.

Government records show United Med Supply Market billed Medicare for more than $2 million, mostly for wound care.

Following an investigation by the inspector general, the business was suspended from billing for Medicare payments.

Ali Ghraoui, general manager of the Miami Merchandise Mart, told CNBC in a February interview that United Medical vacated that space and that he was working to improve the image of the mall.

Still, as Pérez Aybar points out, there’s always another fraudulent operation ready to bilk the system.

“South Florida, without question, is the ground zero for health-care fraud, but it’s only one state. There are 49 others and territories where these types of schemes are occurring,” he said.

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EXPANSION- Medicaid Expansion Fails to Deliver on Promises

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]: Some findings you won’t like. Move along and don’t read this.

 
 

Clipped from: https://www.bhpioneer.com/medicaid-expansion-fails-to-deliver-on-promises/article_ae83199d-8811-51b9-974e-65f9c1b02cc4.html

 
 

 
 

Medicaid expansion is failing states across the nation according to a recent Foundation for Government Accountability (FGA) report. The report found states that have expanded Medicaid have faced more hospital closures than states that haven’t expanded the program. Of course, for years, advocates have claimed that expansion would be a necessary provision for financial health and job security for hospitals. Though, as suspected, data reveals the opposite. More accurately, non-expansion states have seen improved profitability, a larger bed capacity, and increased job growth. 

For quite some time, expansion advocates have made the promise that Medicaid expansion would lead to economic booms for states, creating jobs and improving hospital finances, but the program’s launch clearly tells a different story.

By expanding Medicaid through the Affordable Care Act (ACA), colloquially known as “Obamacare,” the federal government hoped to provide care for a larger share of low-income Americans. Under the ACA, states now have the option to expand their Medicaid programs to cover adults 65 and under with incomes up to 138% of the federal poverty level and an enhanced federal matching rate (FMAP) for their expansion populations. FMAP varies by state but allows the Centers for Medicare & Medicaid Services to reimburse each state for a percentage of its total Medicaid expenditures. As of now, 38 states have adopted Medicaid expansion.

States that have enacted the expansion are consequently awaiting success but face unrealized promises. Moreover, in the first year of the program, nearly 40% of expansion states lost hospital jobs.

Here are the grim statistics from FGA’s report:

  • 1 in 5 expansion states saw hospital job losses.
  • From 2013 to 2016, Medicaid shortfalls at hospitals in expansion states grew by nearly 50%.
  • Nearly 50 hospitals, many of which were rural facilities, shut their doors after expansion was implemented.
  • Only 5% of hospitals directly cited a lack of Medicaid expansion in their list of reasons for closure; however, half of these hospitals were involved in alleged fraud or severe financial malpractice.
  • 1 in 4 rural hospitals in expansion states are at risk for closure.

The report also highlights the flaws in the health systems of Appalachian states, many of which have expanded Medicaid. The report states that the Ohio Valley Medical Center in Wheeling, West Virginia and East Ohio Regional Hospital in Martins Ferry, Ohio closed in 2019 resulting in the release of roughly 1,200 hospital workers. According to the report, hospitals partly accredited the closures, creating $37 million in losses, due to the “lower-reimbursing Medicaid program.”

Likewise, in the month prior to expansion, West Virginia had 40,100 hospital jobs. A year later, that number fell to 39,728 – the opposite of what has been seen in non-expansion states. States that have maintained non-expansion Medicaid, over a period of five years, enjoyed 14% faster hospital job growth than expansion states. 

Many states across the nation are still facing the same health care issues from before implementation of Medicaid expansion. Despite haughty claims that Medicaid expansion would be the elixir to cure hospital pains, the evidence is clear that the expansion “tool” is just not enough. Hospitals continue to close.

Jessica Dobrinsky Harris is a Policy Analyst at the Cardinal Institute for WV Policy.

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EXPANSION- Medicaid expansion recognized as significant missed opportunity

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]: Wyoming expansioners will have to try again next year.

 
 

Clipped from: https://www.wyomingnews.com/wyomingbusinessreport/industry_news/government_and_politics/medicaid-expansion-recognized-as-significant-missed-opportunity/article_c9572924-c1ae-11ed-ae2f-f3cbae49974d.html

 
 

Bob Mathia, right, frowns in response to testimony opposing House Bill 80 during a meeting of the House Revenue Committee at the Wyoming State Capitol in Cheyenne on Jan. 19. The committee passed HB 80, titled “Medical treatment opportunity act-Medicaid reform,” to expand Medicaid eligibility, with a 6-3 vote, but it was never considered on the House floor.

Alyte Katilius/Wyoming Tribune Eagle

CHEYENNE — One-hundred and ninety-six bills passed out of the Wyoming Legislature during the general session, but that doesn’t mean nothing was left on the table.

Lawmakers recognized there were missed opportunities, while still applauding steps toward saving hundreds of millions of dollars, providing property tax relief, improving maternal health care access or securing elections. They had 500 pieces of legislation to process in a two-month period filled with chamber deadlines, and every bill couldn’t receive the attention required to move forward.

However, there was one bill that legislators on both sides of the aisle emphasized they were disappointed was left to die.

House Bill 80 would have expanded Medicaid in Wyoming, providing coverage to an anticipated 19,000 new enrollees by the end of the first biennium. The legislation was developed and sponsored by the Joint Revenue Interim Committee, as well as passed out of the House Revenue Committee in the first two weeks of the session.

Six of the nine committee members recommended it pass and be placed on general file, but the chamber was never given the chance to debate its perceived merits or downfalls. House Majority Floor Leader Chip Neiman, R-Hulett, said he wouldn’t let it onto the floor before the first Committee of the Whole deadline out of concern for the state.

House support

House Revenue Committee Chairman Steve Harshman, R-Casper, has been voting against expanding Medicaid for nearly a decade, but he became an advocate for the bill this year. He told the Wyoming Tribune Eagle it was one of the most significant losses during the session.

“When we look at experiences around the United States, and when we look at our neighboring sister states, it’s getting more and more obvious that’s part of the solution to provide health care and health insurance to people in Wyoming,” he said. “There’s no doubt.”

He said legislators need to understand it is health insurance for the poor, and that health care providers, business owners and residents want it. Harshman also pushed back against the belief that the federal government can’t be trusted.

“We just asked the federal government to come help save our cattle stranded in a blizzard,” he said.

“We’re part of the United States and part of the federal government.”

Despite the bill not making it through the legislative process, the central Wyoming representative has hope it will come back next session for consideration.

Rep. Karlee Provenza, D-Laramie, was another lawmaker hoping to vote in favor of HB 80 in the House, and she said it was the biggest issue not addressed. She noted there are more residents who are going to lose their Medicaid benefits in the next few months because of the change in federal designation for the COVID-19 emergency, and they won’t qualify.

The House Minority Whip said there will be even more uninsured people in Wyoming that can’t afford health insurance in any other way and won’t have affordable access to services. They will continue to have health issues that cost the state millions in uncompensated care, however, meaning all residents will have to pay for it in some capacity.

“And people will die. That is certain,” she told the WTE. “We’ve been beating the drum for a long time, but every year it just gets worse and worse. There’s more people impacted by it.”

Senate disappointment

While the House nearly got the chance to vote on the bill, the Senate was in no way close.

Sen. Stephan Pappas, R-Cheyenne, said it was a missed opportunity in a productive session, but that’s what it always ends up happening every year he has been in the Legislature. He has always been a supporter of expanding Medicaid, and he doesn’t share the same fears as some of his Republican colleagues about taking federal dollars.

He said leaving the money on the table will not reduce the deficit, as many of them believe, because it gets spent by other states.

Pappas was backed by a fellow Republican on his side of the Wyoming Capitol. Sen. Cale Case, R-Lander, attempted to bring an amendment to the supplemental budget bill after HB 80 gained no traction in the House, and expressed his disappointment.

He said Wyoming is losing the ability to have a healthier and more vibrant population, as well as the chance to keep rural hospitals from losing millions of dollars.

“It affects so many people; it’s so far reaching,” added Sen. Mike Gierau, D-Jackson, who said it was the top missed opportunity. “Even the most anti-government people will tell you that, in some form or fashion, health care for the citizenry isn’t something that the government should be too far away from.”

Other priorities

Expanding the federal program was on the minds of many who left their desks at the end of the session on March 3, but it wasn’t the only legislation or issue weighing on lawmakers.

Some were frustrated with a lack of focus on Wyoming solutions, time that escaped the House chamber or failing to find multiple ways to provide immediate tax relief for residents. Even those who focused on the significance of Medicaid expansion failing pointed out a need for sustainable transportation funding, investments in capital construction or placing more funding in the Wyoming Outdoor Trust Fund.

Sen. Brian Boner, R-Douglas, said he was disappointed that a bill addressing severance taxes for oil and gas companies was voted down in the House Appropriations Committee. He said it was a direct response to President Joe Biden’s administration increasing the royalty rate on federal lands for oil and gas development.

“The proposal was to make a proportional reduction to what they pay on severance taxes in a way that would be net-neutral to state and local government,” he told the WTE. “I look forward to bringing that back next year.”

Another missed opportunity was creating a film incentive program in the state, according to House Majority Whip Cyrus Western, R-Big Horn. He said it died on general file due to an extensive amount of debate taking up time in the weeks preceding the deadline.

It was a program he believed would have been impactful, as shows such as “Yellowstone” and “Joe Pickett” aren’t being filmed in the state.

“That series is filmed in Alberta. And while Alberta is certainly a beautiful place, great mountains, it’s set in Wyoming,” Western said of the series based on C.J. Box’s Pickett character. “And so, those are a couple of pretty glaring examples where we want that money to be invested here in our community.”

Although the session has come to an end, lawmakers are still preparing for work throughout the interim. Any missed opportunities or legislation they felt needed deeper dives will spend months under the microscope in interim committees or can be developed privately by stakeholders and individual sponsors.

The Legislature’s Management Council will meet March 23 to assign interim topics, and the first round of committee meetings begins in April. This will spur a year-long effort to get organized before the 2024 budget session next February.

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PHE- Google search update aims to ease 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]: Google is building out its Medicaid operations suite.

 
 

Clipped from: https://www.modernhealthcare.com/digital-health/google-search-update-medicaid-redeterminations-ai-check-up-event

Google is helping people navigate Medicaid redeterminations with the latest update to its search product, the tech giant said Tuesday morning. 

Google announced several new healthcare initiatives at its annual Check Up event on Tuesday. The updates were related to search, artificial intelligence and interoperability. 

Related: Health industry groups to assist Medicaid enrollees losing coverage

The company is adding a feature to search to provide specific information for users seeking to re-enroll in Medicaid by the end of March. Google said it plans to include state specific information in these searches.

During the public health emergency, people were not required to re-enroll in Medicaid. At the end of March up to 14 million people will no longer be eligible for Medicaid once states start re-checking individual eligibility, according to HHS. States will begin the process of clearing their rolls April 1.

Google has applied its conversational artificial intelligence technology Duplex to verify healthcare providers’ information and whether they accept certain Medicaid plans. Duplex is a voice-enabled technology tool that has called hundreds of thousands of physicians to get this information, Google said.

The search tools will also provide information to users on community health centers near them that offer free or low-cost care. 

Updates to AI projects 

During the event, Google also provided an update on its AI cancer research projects with Mayo Clinic and other health system partners. With Mayo, the company tested whether it was possible to use AI to automatically contour organs by reading CT scans. The process is typically completed manually. 

Results from this research will be published soon but Google said it is extending the research efforts with Mayo. While each individual project can vary, Google said it is broadly looking for partners to co-develop and test solutions.

“What we want to do is look for opportunities where there’s clear space to demonstrate the value-add of artificial intelligence in that particular application space,” said Greg Corrado, lead of the health AI group at Google.  “A partner who’s keen and is capable to realize those benefits in a co-development setting, or in a technology transfer setting [are also important].” 

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The company is also developing AI tools on its own that demonstrate capabilities in language understanding and generation. Google said the tools need more work as the AI displayed “significant gaps” when it came to answering medical questions. These developments come as ChatGPT and conversational AI tools have become more popular for potential medical uses.

At the event, Google also rolled out a series of components called Open Health Stack that allows developers to build digital health apps on an interoperable data standard.

In August 2021, Google unwound its Google Health division and opted instead to redistribute its health efforts across its research, search and device divisions.

This story first appeared in Digital Health Business & Technology.

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STATE NEWS (MT) – Amendment to fund Medicaid provider rates to benchmark fails

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 they didn’t just do what the consultants said. Still increased the provider payments by $88M (but of course providers say that’s still not enough).

 
 

Clipped from: https://billingsgazette.com/lifestyles/health-med-fit/amendment-to-fund-medicaid-provider-rates-to-benchmark-fails/article_b08add74-c289-11ed-8ea0-bba0b8bc9b2a.html

An amendment to further increase Medicaid provider reimbursement rates failed in a 13 to 10 vote Tuesday before the House Appropriations Committee.

Carried by Rep. John Fitzpatrick, R-Anaconda, the amendment would have brought provider rates in line with the benchmarks suggested by Guidehouse, the team commissioned by the state to assess reimbursement falls short in four essential human services departments.

The amendment also added a 3% inflationary increase for each year between 2021 and 2024. An additional 3% increase would have covered 2025.

“The concern I have with this issue is that we’re making a big bet. And the bet is this: we’ve either provided them with enough money so that they can continue on and go through the next biennium and survive. Or two, we’ve short changed them and we’re going to lose service providers,” Fitzpatrick said.

Over the last two years, providers serving a large population of Medicaid recipients reported a 14% increase to their expenditures, much greater than the typical 2% inflation seen in a typical biennium, Fitzpatrick said.

Inflation, provider shortages and wage pressures have pushed services to the brink of closure in the years since the pandemic.

Perhaps the most significant being the 11 nursing homes that closed in 2022. The sudden decrease in skilled nursing beds has created a bottleneck in Montana’s hospital systems, creating a significant financial burden.

Rep. Bob Keenan, R-Bigfork, defended the work done in the Human Services Subcommittee where legislators voted to increase provider rates from the governor’s proposed budget, but did not opt to fully fund rates to the benchmarks.

“We had an opportunity this session to help (with the traditionally low reimbursement rates) and I was pretty excited about it because it’s been fairly lonely trying to advocate for these providers across the state,” Keenan said. “…I resist this amendment just for the simple fact that I’m really proud of what our subcommittee has done at this point in time,” Keenan said.

With the subcommittee’s budget vote, $87.5 million is directed to provider rates. With the Medicaid match, that amounts to $305 million directed into the Medicaid system.

Benchmark rates ‘foundational’

While the infusion of cash marks a historic budgetary increase for these Medicaid providers, dozens of leaders representing organizations for SUD treatment, children and adult behavioral health, nursing homes, in-home care providers, aging services, developmental disabilities, and more encouraged lawmakers to bring reimbursement in line with the benchmark rates.

“Funding these rates is not a fix for everything but it really is foundational. It’s what needs to happen first before we can begin to make a lot of those other fixes within the system,” said Erin McGowan, who spoke in support of fully funding the benchmark rates at an appropriations committee meeting last Thursday. McGowan is a lobbyist for various provider groups across the state including Homecare Montana and Confluence Public Health.

What’s missing from the subcommittee’s budget, said McGowan, is a regular cost of living adjustment that would prevent future underfunding of these services.

Many of the services included in the rate study are highly sensitive to inflation. Group home providers, for example, provide food and transportation to residents. When grocery and gas prices go up, so do the group home’s expenses.

Joshua Kendrick, CEO of Opportunity Montana, said that the rate increase would equate to a wage increase for staff.

Many who spoke during public comment explained that the staffing shortages are, in part, due to the inability to offer a competitive wage to current and future employees who could make better money working in food service.

Over the course of the pandemic, Youth Dynamics, which provides mental and behavioral health services for kids, lost 56 full-time employees and 83 part-time employees, said Dennis Sulser who represented the organization at the hearing.

Since July 1, 2022, 43% of the employees who provided a reason for their departure from Youth Dynamics said it was due to low wage or better job opportunities elsewhere, according to Sulser.

Countless providers expressed to lawmakers that the benchmark rate would just barely bring reimbursement rates up to their current costs.

Nonetheless, health department director Charlie Brereton, again pushed for the governor’s initial budget proposal in the Thursday meeting. The proposal mostly consists of one-time-only funding that would close 58% of the gap between current rates and the benchmark in 2024. In 2025, the rates would decrease, covering only 36% of the gap in 2025.

Brereton said the proposal centered on being responsive.

In an effort to address questions about not fully funding the benchmark rate, Brereton read a statement.

“The benchmark is average costs and reflects a wide array of provider practices. The average costs are important in identifying the accuracy of a rate but ultimately reflect an average of the costs. It’s a compass that shows where we should be headed, but not necessarily a minimum of what is needed to stabilize any provider type,” Brereton said.

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Medicaid Pre-Release Enrollment – Coordinator 2 – Baton Rouge, LA

Clipped from: https://www.indeed.com/viewjob?jk=1f6c903e10157f2e&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Indeed’s salary guide

  • Not provided by employer
  • $58.8K – $74.4K a year is Indeed’s estimated salary for this role in Baton Rouge, LA.

Thank you for your interest in The University of New Orleans.

Once you start the application process, you will not be able to save your work, so you should collect all required information before you begin. The required information is listed below in the job posting.

You must complete all required portions of the application and attached the required documents in order to be considered for employment.

Department

Compliance Operations

Job Summary

The MPRE Coordinator 2 position is part of a three-member team that supports Medicaid’s Justice-involved Pre-Release Enrollment Program as well as other justice-involved initiatives undertaken by Medicaid. The Pre-Release Enrollment Program provides Medicaid coverage for the offender population and is a collaborative effort, working with the Louisiana Department of Public Safety & Corrections (DPS&C) and partners with community groups that work with formerly incarcerated persons. A key role of this position will be to advance the monitoring and evaluation of the program. This position is domiciled at the Louisiana Department of Health’s office in Baton Rouge, Louisiana.

Job Description

  • Assist the LDH Program Manager in all areas of daily program functions including researching Medicaid eligibility and resolving application issues, ensuring the accuracy of program data, communicating with stakeholders, and periodic program monitoring.
  • Work collaboratively with staff of DPS&C’s prison facilities, Medicaid’s managed care plans, and other LDH programs.
  • Assist with the coordination, planning and evaluation of Medicaid’s Pre-release Enrollment Program and other justice-involved initiatives
  • Assist LDH management with day-to-day tasks and serve as a secondary contact and provide functional back-up support in the unit supervisor’s absence.
  • Research multiple databases to resolve individual Medicaid application and enrollment issues for internal and external partners.
  • Responsible for data analysis and writing monthly, mid-year and annual reports.
  • Represent the department at relevant conferences, regional events and stakeholder meetings. Some in-state travel is expected, including travel to other state offices and correctional facilities.
  • Conduct research on topics related to program or target population as needed.
  • Assist with the preparation and execution of conference calls, webinars, and meetings.
  • Develop and update documentation about the program for internal and external audiences such as operations manuals, reports, white papers, abstracts and fact sheets.
  • Facilitate meetings, trainings as needed.
  • Assist with data integrity efforts including verifying data accuracy.
  • Other tasks as directed.

QUALIFICATIONS

REQUIRED:

  • Bachelor’s degree.
  • Minimum of 1 year professional experience in Medicaid programs, the justice-involved population, or criminal justice system.
  • Minimum 1 year of professional experience with writing business documents such as reports, abstracts and memorandums.
  • Minimum of 1 year of professional experience with planning and leading meetings, committees, or coalitions.
  • Advanced ability to problem-solve and research between multiple computer systems or databases.
  • Proficient in Microsoft Office applications, including Word, Excel, Access and Power Point.
  • Strong verbal and written communications skills and ability to communicate concepts to a range of audiences. .
  • Must be able to pass a background check and gain admittance to correctional facilities.

DESIRED:

  • Master’s degree in health administration, business administration, information technology, or public health, Juris Doctor or other advanced degree in relevant field.
  • Minimum of 2 years professional experience in Medicaid programs, the justice-involved population, or criminal justice system.
  • Minimum of 1 year professional experience with data analysis software such as SAS, SQL, R, Python.
  • Experience with scholarly journal article writing, submissions and publications.
  • Experience with health outcomes/policy research or study/survey design.

Required Attachments

Please upload the following documents in the Resume/Cover Letter section.

  • Detailed resume listing relevant qualifications and experience;
  • Cover Letter indicating why you are a good fit for the position and University of Louisiana Systems;
  • Names and contact information of three references;
  • Diversity Statement (required for all Faculty positions and any Staff position of Assistant Manager and higher).

See Diversity Statement instructions by clicking this link:

https://www.uno.edu/careers/diversity-instructions

Applications that do not include the required uploaded documents may not be considered.

Posting Close Date

This position will remain open until filled.

Note to Applicant:

Applicants should fully describe their qualifications and experience with specific reference to each of the minimum and preferred qualifications in their cover letter. The search committee will use this information during the initial review of application materials.

References will be contacted at the appropriate phase of the recruitment process.

This position may require a criminal background check to be conducted on the candidate(s) selected for hire.

As part of the hiring process, applicants for positions at the University of New Orleans may be required to demonstrate the ability to perform job-related tasks.

The University of New Orleans is an Affirmative Action and Equal Employment Opportunity employer. We do not discriminate on the basis of race, gender, color, religion, national origin, disability, sexual orientation, gender identity, protected Veteran status, age if 40 or older, or any other characteristic protected by federal, state, or local law.

Posted on by

Oklahoma Medicaid CFO, Nicoma Park, Oklahoma

Clipped from: https://starjobsearch.co.uk/jobs/oklahoma-medicaid-cfo-nicoma-park-oklahoma/945468666-2/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Oklahoma Medicaid CFO

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us and start doing your life’s best work.(sm)

 
 

This position is accountable for the day-day development and management of financial models and performance as it relates to business goals and objectives in the Oklahoma Community & State health plan. This position will work with key leaders to ensure that the business is operating effectively, with sound financial analysis, and with appropriate financial and operating controls in place.

 
 

Primary Responsibilities:

 
 

 
 

  • Confirms compliance with the SoonerSelect program regulatory requirements (e.g., quarterly/annual filings) and other program operational areas (e.g., rate changes, fee-schedule changes, revenue reconciliation, reporting) and oversees all audit activities

 
 

  • Develops, performs and manages analyses of business/financial metrics and performance measures and reports financial and operational data to region/site leaders

 
 

  • Develops and maintains financial reports to clearly communicate actual results, forecasted performance, and variances to plan, forecast and budget

 
 

  • Works closely with health plan executives to develop, recommend and establish strategies, plans and processes to improve profitability and cost efficiencies

 
 

  • Leads the financial management of capital, operating expense and develops metrics, benchmarks, and analytics to guide the appropriate investment in infrastructure

 
 

  • Establishes detailed budgets and identifies, quantifies, and prioritizes strategic initiatives to realize these budgets

 
 

  • Assists with trend analysis and forecasting

 
 

  • Assists with development and operationalizing medical cost reporting

 
 

  • Engages in monthly close process

 
 

 
 

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

 
 

RELOCATION IS AVAILABLE

 
 

Required Qualifications:

 
 

 
 

  • Bachelor’s degree in Finance, Accounting, or equivalent field

 
 

  • 8+ years of broad experience in multiple Finance disciplines

 
 

  • Experience reporting to Executive Leadership in a strategic partnership capacity

 
 

  • Advanced knowledge of Health Care industry (2+ years minimum of healthcare finance experience)

 
 

  • Solid working knowledge of financial systems, statements and reports

 
 

 
 

Preferred Qualifications:

 
 

 
 

  • MBA or CPA

 
 

  • Medicaid and/or Medicare experience

 
 

  • Demonstrated success partnering with leading and influencing multiple teams responsible for complex operations

 
 

  • Ability to complete complex projects and influence change in complicated, fast paced, matrix environment

 
 

 
 

Posted on by

PRODUCT MANAGER ( MEDICARE ADVANTAGE, MEDICAID) | Bestinfo Systems LLC

Clipped from: https://www.linkedin.com/jobs/view/product-manager-medicare-advantage-medicaid-at-bestinfo-systems-llc-3520895550/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

PRODUCT MANAGER ( MEDICARE ADVANTAGE, MEDICAID)_ALL USA_Full-Time(FTE)

 
 

Hi,

Greetings from Bestinfo Systems LLC!!

We have a job opportunity that matches your profile.

Kindly check the below position and revert me with your updated resume along with salary expectations and location preference

 
 

Job Title: PRODUCT MANAGER ( MEDICARE ADVANTAGE, MEDICAID)

Location: The job is fully remote, no location is specified

Job Type: Full-Time(FTE)

Industry: Healthcare / Health Services

Job Category: Medical / Health – Other Medical / Health

 
 

Job Description:

Primary duties may include, but are not limited to:

Evaluates existing products and competitor and industry data to improve existing products and make recommendations for new products.

Coordinates presentation, communication, and implementation of all phases of product development.

Ensures products meet competitive, regulatory (CMS, NCQA), and compliance needs.

Reviews analyze, and makes recommendations on actions for existing products.

Investigates market opportunities and effect on the market for existing and new products.

Identifies system needs to support short- and long-term product strategy.

 
 

Qualifications:

Requires a BA/BS degree in a related field and a minimum of 2 years of related experience(Or)

Any combination of education and experience would provide an equivalent background.

 
 

Preferred Skills, Capabilities, and Experience:

MBA

Health or managed care experience

Strong strategic managed care understanding for Medicare Advantage, Medicaid, and Commercial and chronic complex populations.

Extensive knowledge of CMS, and NCQA regulatory guidelines.

Aptitude for independent strategic thinking as well as the ability to identify, leverage, and execute best practices while demonstrating a continuously innovative mindset.

Critical thinker/problem solver is willing to take initiative with minimal direction.

 
 

SKILLS AND CERTIFICATIONS:

Healthcare Experience

medicare advantage

Medicaid

 
 

IDEAL CANDIDATE:

Strong strategic managed care understanding for Medicare Advantage, Medicaid, and Commercial and chronic complex populations.

Extensive knowledge of CMS, and NCQA regulatory guidelines.

Posted on by

LTSS Medicaid Operations Director – Remote at UnitedHealth Group

Clipped from: https://www.themuse.com/jobs/unitedhealthgroup/ltss-medicaid-operations-director-remote?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

This subject matter expert role will provide insights into long term care services (LTSS) operational complexity to support of fully/partially integrated programs. This leadership role supports product fluidity to comply with CMS guidance directing payers to prepare to have fully integrated Medicare/Medicaid capabilities going forward.

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

 

  • Provide program operational and regulatory expertise for LTSS/HCBS integrated services including but not limited to assessment, service planning, care coordination, transition planning, consumer hearings, member and caregiver education and training, compliance with program requirements, rules, and regulation
  • Partner with provider relations team to develop content to support provider management functions for Providers of HCBS services including but not limited Support content for program policies procedures and protocols that are aligned with federal and state requirements and community education program
  • Contribute to strategies which foster best in class service to the Health Plan, State Department of Medicaid, CMS and Corporate
  • Contribute to the operational strategic vision, objectives, policies, and procedures related to LTSS/HCBS
  • Identify operational efficiencies; meet regulatory and corporate expectations and develop a “best practice” approach to the defined operational areas
  • Identifies tactics to meet and exceed requirements including organizational, state, accreditation, compliance, and contractual agreements
  • Assess program strengths and weaknesses to recommend and deliver enhanced operating model
  • Participate in business development and membership growth including procurement and re-procurement activities

You’re ready to take on an incredibly challenging marketplace of ideas, products, and services. But are you up for leading the transformation of an entire industry? Here, you’ll work with the smartest people on solving the most important problems our nation is facing. The tasks are huge, the impact is far-reaching -it’s the best chance to test your mettle on a global stage.


You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.


Required Qualifications:

 

  • Undergraduate degree or equivalent experience
  • 5+ years of experience with managed healthcare, preferably in Medicaid ABD, LTSS and/or Medicare
  • Demonstrated exceptional verbal (e.g., Public Speaking) Writing /Composing: Correspondence /Reports Analytical, MS Word, MS Excel

Preferred Qualification:

 

  • 3+ years management experience

Already Fortune 5, we are totally focused on innovation and change. We work a little harder. We aim a little higher. We expect more from ourselves and each other. And at the end of the day, we’re doing a lot of good.

Through our family of businesses and a lot of inspired individuals, we’re building a high-performance health care system that works better for more people in more ways than ever. Now we’re looking to reinforce our team with people who are decisive, brilliant – and built for speed.

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

California, Colorado, Connecticut, Nevada, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New York, Rhode Island or Washington residents is $118,000 to $226,800. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy


At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes – an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.


UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.