Category: MM Curator

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STATE NEWS- Texas Medicaid: Pediatric formula prior authorizations

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]: A blast from the past. Remember the COVID formula shortage?

 
 

Clipped from: https://www.uhcprovider.com/en/resource-library/news/2023/tx-medicaid-pediatric-formula-waiver-ending.html

January 13, 2023

Texas Medicaid: Pediatric formula prior authorizations

On Feb. 28, 2023, our temporary waiver of prior authorizations for pediatric formula will end. Starting March 1, 2023, you must submit prior authorization requests for UnitedHealthcare Community Plan of Texas members. The waiver was in place to help support you and our members during the nationwide formula shortage. 

Visit the Prior Authorization and Notification page for information on how to submit prior authorization requests in the UnitedHealthcare Provider Portal.

Questions?

Please reach out to your provider advocate or call Customer Service at 888-887-9003, 8 a.m.–6 p.m. CT, Monday–Friday.

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FWA- Ob-gyn can keep $205,000 in Medicaid pay that state tried to recoup

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]: A an OB that decided to pivot and focus on primary care (when ACA incentivized it) to meet the needs in their area can keep the payments for delivering said care.

 
 

Clipped from: https://www.ama-assn.org/practice-management/medicare-medicaid/ob-gyn-can-keep-205000-medicaid-pay-state-tried-recoup

A Hawaii ob-gyn who also provided primary care services to patients in an underserved area is entitled to retain the $205,000 in enhanced Medicaid payments the government was trying to recoup from him, the state supreme court has ruled.

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Hilo physician Frederick Nitta, MD, spent more than 60% of his time providing primary care to patients in the medically underserved area in which he practices medicine. But state officials claimed that he couldn’t collect higher Medicaid payments created under a 2010 law designed to encourage physicians to provide this care.

The Hawaii Department of Human Services (DHS) also had demanded that he pay back the $205,000 he had already been paid for the care he provided Medicaid patents and billed for at the higher rate.

After years of litigation, Hawaii’s highest court ruled in the physician’s favor.

“Congress clearly intended the enhanced payments as incentives for the provision of primary care services, regardless of a physician’s other practice areas,” the Hawaii Supreme Court said in its  November ruling (PDF).

The court quoted extensively from the amicus brief (PDF) that the Litigation Center of the American Medical Association and State Medical Societies and the Hawaii Medical Association (HMA) filed when Nitta v. Department of Human Services, State of Hawaii was at the appellate court level.

Related Coverage

4 ways the AMA has battled in court to preserve access to care

“Amici highlighted the critical and worsening physician shortage in Hawai’i, noting that primary care has the greatest shortage, especially for Medicaid patients in East Hawai’i,” the Hawaii Supreme Court said, noting that DHS’ “continued recoupment efforts against physicians providing primary care services to Medicaid beneficiaries only worsens the shortage.”

The court referenced the AMA Litigation Center and HMA brief (PDF) cited articles and other reports that showed “‘on neighbor islands, in particular, patients often wait four to five months for a doctor’s appointment. On Hawai’i Island, it is sometimes two to three times more difficult to find a PCP [primary care physician]. Consequently, many residents seek care at the nearest hospital emergency room, costing them ‘upward of $600–$800 for an emergency room visit, as opposed to the average co-ay of $15–$50 for a visit to a primary care physician.'”

Who qualifies as “primary care?”

The Hawaii DHS had argued to the state supreme court that medical directory listings were the deciding factor of a physician’s practice characteristics. In refuting that argument, justices again referred to the AMA Litigation Center and HMA brief, noting that it “urged that the payments to Dr. Nitta were consistent with the ACA’s purpose to ‘benefit physicians that provide primary care services to the Medicaid population.'”

The AMA-HMA brief also pointed to Centers for Medicare & Medicaid Services (CMS) published questions and answers regarding how states can review a physician’s eligibility for the enhanced payment program.

“There, the CMS provided a nonexhaustive list of ways a state could verify a physician’s practice characteristics (i.e., how the physician represented himself in the community, medical directory listings, billings to other insurers, advertisements, etc.),” the court’s opinion said.

The AMA-HMA brief also “contended other evidence demonstrated Dr. Nitta’s PCP status,” the court noted. That includes “recognition by other doctors and medical providers in the East Hawaii community as a PCP,” and “acceptance and payment by medical insurers and a PCP” and “hundreds of written and oral testimony by people in support of a finding that he is a PCP.”

Related Coverage

“Arbitrary” action has doctor on hook for $205,000 in bonus pay

And finally, the court cited the amicus brief’s argument that the DHS ” ‘formula to determine the sixty-percent-threshold requirement [was] in complete disregard for actual medical practice'” because paid billing codes don’t take into account the “‘percentage of total services provided in a managed care environment by that physician.’ “

Dr. Nitta reflected on the case in an interview with the Hawaii Tribune-Herald.

“I could have just paid them back. Instead, it’s probably costing me more to fight them in court over and over and over. But that doesn’t matter, because it’s not right what they’re doing.”

Find out more about the cases in which the AMA Litigation Center is providing assistance and learn about the Litigation Center’s case-selection criteria.

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FWA- Birmingham company to pay $153,300 on false Medicaid claim allegations

MM Curator summary

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

 
 

[MM Curator Summary]: A software design error caused Connecticut to overbill for ABA services.

 
 

Clipped from: https://www.al.com/business/2023/01/birmingham-company-to-pay-153300-on-false-medicaid-claim-allegations.html

Birmingham-based Amvik Solutions is paying $153,300 to resolve allegations that it submitted false claims for payment to Connecticut’s Medicaid program, federal officials announced today.

Federal officials announced the civil settlement with the government, which resolves allegations under the federal False Claims Act. The case involved the Justice Department, the Department of Health and Human Services and the Federal Bureau of Investigation.

Amvik Solutions offers billing, claims and collection services for healthcare providers throughout the U.S., using its proprietary WebABA software.

According to the DOJ, Amvik was hired to handle billing and claims for Helping Hands Academy, a Bridgeport, Conn. services provider working with children with autism.

The government alleges that when submitting claims for payment to Connecticut Medicaid on behalf of Helping Hands, Amvik falsely identified the incorrect Board Certified Behavior Analyst (“BCBA”) as the rendering provider on the claims.

This caused Connecticut Medicaid to pay claims that it would not have otherwise paid, investigators said. The action took place from Oct. 3, 2019 to Oct. 1, 2020.

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FWA- Healthcare billing fraud: 13 recent cases

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]: A nice little round-up of Medicaid fraud.

 
 

Clipped from: https://www.beckershospitalreview.com/legal-regulatory-issues/healthcare-billing-fraud-13-recent-cases.html

From a Florida physician getting 20 years in prison for the “largest ever” case of its kind, to a New York gastroenterologist getting 30 months in prison for a Medicare fraud scheme, here are 13 healthcare billing fraud cases Becker’s has reported since Dec. 29. 

1. Medical billing company settles false claims allegations

Birmingham, Ala.-based medical billing company Amvik has agreed to pay $153,300 to settle allegations that it submitted false claims to the Connecticut Medicaid program for applied behavior analysis services. 

2. North Carolina lab owner convicted in $11M Medicaid fraud scheme

North Carolina lab owner Donald Booker was convicted for his role in a scheme to defraud the state’s Medicaid program with medically unnecessary urine tests. 

3. Mississippi provider pays $1.8M to settle overbilling allegations

A Mississippi orthopedic clinic and its owner, Hanna “Johnny” Mitias, MD, agreed to pay $1.8 million to settle allegations he overbilled Medicare and Medicaid for viscosupplementation agents.

4. 3 companies settle for $745K for misbranded migraine devices

Medical device distributor Jet Medical and two related companies agreed to pay $745,000 for allegedly instructing, coaching and encouraging medical providers to submit improper billing codes to Medicare for services involving migraine headache devices not approved by the FDA. 

5. Lab owner wanted for alleged Medicare cancer testing scam

Khalid Satary, the owner of several labs in Georgia, Oklahoma and Louisiana, is a wanted fugitive for alleged fraud involving unnecessary cancer genetic testing that resulted in billing Medicare for more than $547 million. After failing to appear at a Dec. 12 court date, Mr. Satary was declared a fugitive of justice and is believed to be in Dubai.

6. Georgia physician to pay $1.85M to settle false claim allegations

Conyers, Ga., physician Aarti Pandya, MD, has agreed to pay $1.85 million to resolve allegations that she knowingly submitted false claims to Medicare, including for cataract surgeries and diagnostic tests that were not medically necessary, tests that were incomplete or of worthless value, and office visits that did not provide the level of service claimed.

7. Former Florida physician gets 20 years prison in ‘largest-ever’ case of its kind

Former Florida physician Michael Ligotti, DO, was sentenced to 20 years in prison and ordered to surrender his medical license after pleading guilty to an addiction fraud treatment scheme that accounted for more than $746 million in billings to federal and private insurers and about $127 million in reimbursements. 

8. Texas lab owners charged in $107M Medicare fraud scheme

The owners of the Lewisville, Texas-based Trinity Clinic are accused of allegedly acquiring thousands of Medicare beneficiaries DNA specimens and corresponding prescriptions that the laboratory used to fraudulently bill the Medicare and Medicare Advantage for genetic testing. The men allegedly concealed the kickbacks through sham contracts for marketing and other services.

9. South Carolina man sentenced to 7 years in prison for stealing providers’ identities, Medicaid fraud

Jonathan Sumter, owner of PHC Supportive Services — a company that purported to provide behavioral healthcare to disabled, low-income individuals — was sentenced to more than seven years in federal prison for stealing the identities of providers and Medicaid recipients and billing South Carolina Medicaid for more than $1 million in false claims.

10. Arkansas cardiologist pays $900K to settle Medicare fraud allegations

Hot Springs, Ark.-based cardiologist Jeffrey Tauth, MD, agreed to pay more than $900,000 to settle allegations he submitted claims to Medicare for medically unnecessary placement of cardiac stents. 

11. New York physician gets 30 months in prison for Medicare fraud

New York gastroenterologist Morris Barnard, MD, was sentenced to 30 months in prison for billing Medicare more than $3 million for colonoscopies and other procedures that were not performed. 

12. Cardiologist pays $931K to settle lab test kickback allegations

Kentucky cardiologist Dr. Kishor Vora paid $931,500 to settle allegations he took kickbacks from a testing lab. 

13. Louisiana physician pleads guilty to Medicare fraud scheme

East Baton Rouge, La.-based physician Robert Dean, MD, pleaded guilty to his role in a $1.3 million Medicare fraud scheme in which he allegedly falsified medical orders for knee braces, claiming he examined and performed tests on patients he never met face to face. 

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FWA- $6.2 million in benefit overpayments recovered during first quarter of fiscal year

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]: Don’t let anyone tell you member fraud is not real. This article is about $6.2M in recoveries (so probably 10x that in losses) for just one quarter.

 
 

Clipped from: https://oig.hhs.texas.gov/about-us/news/62-million-benefit-overpayments-recovered-during-first-quarter-fiscal-year

The OIG’s Benefits Program Integrity (BPI) unit completed 3,205 investigations involving some form of benefit recipient overpayment or fraud allegation in the first quarter of fiscal year 2023. These efforts led to $6,255,879 in recoveries, 5 cases referred for prosecution and 187 cases referred for administrative disqualification.

Most completed investigations involved applicants misrepresenting the number of income-earning household members. Programs like the Supplemental Nutrition Assistance Program (SNAP), Medicaid and others use household composition and income to determine a client’s eligibility for assistance and the proper benefit amount. Below is a selection of SNAP fraud cases involving program clients.

Dallas SNAP client pleads guilty to fraud

In September, a Dallas woman pleaded guilty in Texas District Court on charges of illegal possession of Supplemental Nutritional Assistance Program (SNAP) benefits. The charges stemmed from an investigation by the OIG.

The 1996 Federal Welfare Reform Act requires states to permanently disqualify individuals from the SNAP program if they have a felony drug conviction for conduct occurring after August 22, 1996. Applicants must provide truthful information to the state and notify the State of any past felony drug convictions during the application process.

The individual in question applied for SNAP benefits on January 31, 2011, and claimed under penalty of perjury that she had no such felony drug convictions. However, OIG investigators uncovered evidence that she was convicted of Unlawful Possession of a Controlled Substance, a state jail felony, on April 15, 2004.

The investigation showed that from January 2011 through November 2012, the defendant failed to disclose the conviction on five separate applications for SNAP benefits, receiving $9,252 in excess benefits. As a result, she was sentenced to three days in county jail and permanently disqualified from the SNAP program.

Olney woman convicted for SNAP fraud

A woman in Olney was found guilty in an administrative hearing of committing an Intentional Program Violation. The verdict is the result of an investigation by the OIG.

The individual applied to receive SNAP benefits on October 20, 2017. Because eligibility is tied to household resources, applicants must provide truthful information to the state and notify the state if their household’s composition or income changes.

In her application, the defendant claimed under penalty of perjury that the household consisted of only herself and two children. However, OIG investigators uncovered evidence that the children’s father was, in fact, living in the home and receiving income from a full-time job.

The investigation revealed that over more than four years, the perpetrator received $21,148 in excess benefits because of the fraudulent, unreported information. As a result, she was disqualified from the SNAP program for 12 months and ordered to pay full restitution.

Hidalgo County SNAP and Medicaid client pleads guilty to theft

A Hidalgo County resident pleaded guilty to felony theft after an investigation by the OIG.

The individual applied to receive SNAP benefits on August 19, 2015. In her application, the defendant claimed that the household’s income was from her employment. However, OIG investigators found that the defendant had consistent U.S. currency deposits into her and her husband’s joint bank account that she did not report during the application process. Had she truthfully disclosed the household income, her benefits would have been drastically reduced since household resources determine eligibility.

The defendant continued to falsely report the household income for almost four years, from August 2015 through May 2019. In total, the defendant obtained $20,397 in SNAP benefits and $11,514 in Medicaid benefits she was not entitled to receive.

In September 2022, she was sentenced to 10 years of probation and ordered to pay $31,911 in restitution to Texas Health and Human Services.

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FWA- Buffalo man sentenced to one-year probation, defrauded Medicaid of thousands

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]: Saleh Mozeb and friends nabbed $12k in a rides not delivered scam.

 
 

Clipped from: https://www.wkbw.com/news/local-news/buffalo-man-sentenced-to-one-year-probation-defrauded-medicaid-of-thousands

 
 

BUFFALO, N.Y. (WKBW) — U.S. Attorney Trini E. Ross announced Tuesday that a Buffalo man was sentenced to serve one-year probation and ordered to pay over $12,000 in restitution after being convicted of healthcare fraud.

The defendant, 67-year-old Saleh Mozeb, served as part owner and driver for Great Lake Transportation, a company that offered transportation services for Medicaid recipients.

Between September 2010 and Dec. 31, 2020, drivers for Great Lake Transportation, including Mozeb, submitted false records to Medical Answering Service – a Medicaid transportation management company that schedules transportation services for Medicaid recipients.

Mozeb claimed that transportation services had been provided to Medicaid recipients when in actuality, no transportation services were provided.

As a result of the conviction, Mozeb was sentenced to one-year probation and ordered to pay $12,619 in restitution payment.

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PHE- Navigating the New FMAP Glidepath – FMAP Changes in the Consolidated Appropriations Act of 2023

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 is now a schedule of decreasing FMAP to land the plane by year end. Sort of. If you follow all the rules exactly like CMS says you should (think Van Halen and green M&Ms).

 
 

Clipped from: https://www.dentons.com/en/insights/alerts/2023/january/5/navigating-the-new-fmap-glidepath

 
 

In response to the COVID-19 pandemic and the expected economic downturn, Section 6008 of the Families First Coronavirus Response Act of 2020 (Families First) established a temporary 6.2% increase in the Medicaid federal medical assistance percentage (FMAP), effective January 1, 2020, to last through the last day of the calendar quarter in which the COVID-19 public health emergency (PHE) ended. One condition of the FMAP increase was a prohibition on Medicaid disenrollment during the PHE.

The Consolidated Appropriations Act of 2023 (Pub. L. 117-328) – enacted over the holidays – makes several notable changes to the FMAP increase and related Medicaid eligibility redetermination and disenrollment requirements. Although these FMAP changes are obviously important to States, they are also important to providers and local government entities that may be funding the non-federal share of Medicaid payments through intergovernmental transfers or provider taxes. 

FMAP Increase Transition Period

Section 5131 of Division FF of the Consolidated Appropriations Act of 2023 establishes a “transition period” for the Families First FMAP increase:

Time periodIncrease

  

  

January 1, 2020 through March 31, 2023

6.2 percent

April 1, 2023 through June 30, 2023

5 percent

July 1, 2023 through September 30, 2023

2.5 percent

October 1, 2023 through December 31, 2023

1.5 percent

New Conditions

Section 5131 also imposes new conditions on States’ receipt of the enhanced FMAP during the transition period beginning April 1, 2023.  In particular:

Eligibility Redeterminations.— A State that fails to meet any of the following conditions will not qualify for the FMAP increase for the applicable calendar quarter:

  • Eligibility redeterminations must be in accordance with all Federal requirements.
  • The State must attempt to ensure up-to-date contact information (including a mailing address, phone number, and email address) for each eligibility redetermination using the National Change of Address Database Maintained by the United States Postal Service, State health and human services agencies, or other reliable sources of contact information.
  • The State may not disenroll any individual based on returned mail unless the State first undertakes a good faith effort to contact the individual using more than one modality.

Note that these requirements do not prohibit a State from initiating renewals, post-enrollment verifications, and redeterminations over a 12-month period for all individuals who are enrolled in the State’s Medicaid program as of April 1, 2023.

Reporting Requirements.—The FMAP for a State that does not satisfy new reporting requirements will be reduced by 0.25 percentage points times the number of fiscal quarters for which the State has failed to satisfy such requirements, although the reduction can be no greater than 1 percentage point. Specifically, beginning April 1, 2023 and lasting through June 30, 2024, each State will be required to submit monthly reports to the Department of Health and Human Services (HHS) on the State’s activities relating to eligibility redeterminations, including, but not limited to, the number of eligibility renewals initiated and the number of individuals whose Medicaid coverage was terminated. These reports will be publicly available.

In addition, if HHS determines that a State did not comply with eligibility redetermination and reporting requirements during the April 1, 2023 to June 30, 2024 period, HHS may, in addition to other remedies, require that the State submit and implement a corrective action plan. If a State fails to submit or implement an approved corrective action plan, HHS may require the State suspend making all or some eligibility terminations and may impose civil money penalties of up to $100,000 per day.

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MCOs, CA- Medi-Cal adds more insurance plans after pushback

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]: Move the L for CA community plans to the W column.

 
 

 
 

Clipped from: https://calmatters.org/health/2023/01/medi-cal-insurance-plans/

In summary

State health officials last year launched a first-ever competitive bidding process for its Medi-Cal insurance contracts, aiming to implement higher standards. But when the winners were announced, several insurers complained about the process and potential impact on patient care.

Lea este artículo en español.

In a significant course change, the California Department of Health Care Services announced that it has negotiated with five commercial health plans to provide Medi-Cal services in 2024, scratching a two-year-long bidding process for the coveted state contracts.  

This upends the state’s previous plans of awarding contracts to only three health plans. It  means more Medi-Cal enrollees will likely get to keep their current insurer and doctors, averting a confusing re-enrollment process for most members and preventing disruption to patient care. It also means that the state will avoid a protracted legal battle amid lawsuit threats from insurers who had previously been left out. 

The big winners: Blue Shield and Community Health Group will get a contract after initially having lost bids, and Health Net will get to keep at least some of its Los Angeles enrollees. 

“To bring certainty for members, providers and plans, the State used its authority to work directly with the plans to re-chart our partnership and move with confidence and speed toward the implementation of the changes we want to see,” the department wrote in a statement released Friday afternoon. The department did not provide answers to follow-up questions before publication. 

“At some level it makes the transition easier, but we want to do better than the status quo,” said Anthony Wright, executive director of Health Access, a consumer advocacy group. “Less disruption is good, but we don’t want to lose the reason for the change, which is to have more accountability on these plans going forward.”

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Medi-Cal provides health coverage to more than 14 million low-income Californians, more than a third of the state’s population. In 2021, the Department of Health Care Services, which oversees the Medi-Cal program, embarked on a bidding process that would allow it to rework contracts with commercial Medi-Cal health plans.  The state’s goal was to reduce the number of participating health plans from the current nine and move forward with only the most qualified plans, which would be held to higher standards related to patient outcomes, wait times and satisfaction, as well as improving health disparities. 

In August of last year, the state announced that it would tentatively award $14 billion worth of Medi-Cal contracts to three companies — Health Net, Molina and Anthem Blue Cross. This proposed decision would force close to 2 million Medi-Cal enrollees to switch insurance and likely find new providers. Some health providers decried the department’s original contract decision, claiming it would have caused “immeasurable” disruption to care.

 “Less disruption is good, but we don’t want to lose the reason for the change, which is to have more accountability.”

Anthony Wright, executive director of Health Access

Kaiser Permanente negotiated a special contract with the state early last year, bypassing the bidding process. And most nonprofit community-based health plans did not have to compete for a contract.

The state’s summer announcement quickly became controversial as health plans that were left out questioned the state’s process for choosing the three insurers, appealed the decision and sued the state. 

This change of course calls into question the power that insurance companies can have in pressuring state action with legal threats. Health advocates say they hope it does not set a precedent. Wright at Health Access said he’d like for the department to make clear that the state is not backing away from the competitive contract process in the future, as he considers it is a key tool for accountability. 

Blue Shield, one of the insurance companies initially left out, filed a complaint against the Department of Health Care Services, requesting that the department release all documents used in the selection process. 

The insurance giant even launched a campaign in the fall asking Californians to speak out against the state’s decision. The company argued that the state failed to sufficiently engage Medi-Cal enrollees and doctors in the process. “The message of this campaign is that it’s not too late for the state to change course and make choices that will advance innovation and health equity for everyone,” Kristen Cerf, president and CEO of Blue Shield’s Medi-Cal plan, said in a statement in October. 

Under the revised agreement, Blue Shield will get to keep serving the San Diego area. Blue Shield declined a request for an interview, instead referring reporters to a statement released Tuesday. 

Meanwhile, Health Net, which in the summer was tentatively awarded contracts in nine counties but lost its previous and largest contract in Los Angeles, also sued the state. Under the new agreement, Health Net will get to stay in Los Angeles and will divide its share of Medi-Cal enrollees evenly with its commercial counterpart, Molina Healthcare. Health Net will also keep its Sacramento membership but lose the San Diego market.

Centene, the parent company of Health Net, said in a Tuesday statement that it would end its legal actions against the state’s health services department.

The splitting of members evenly between Molina and Health Net through a subcontracting agreement is a “step in the right direction,” said Jim Mangia, president and CEO of St. John’s Community Health, which serves low-income patients in south LA, but much remains uncertain.

“Who’s the 50 percent that are going to be able to stay with Health Net and who are the 50 percent that are going to have to move?” Mangia said. “We don’t have answers to that, so I think it’s problematic in that it still displaces a significant number of patients.”

Currently, Health Net manages more than 1 million Medi-Cal patients in Los Angeles County. Nearly a quarter of St. John’s Community Health patients have Health Net, with the publicly run L.A. Care Health Plan accounting for the rest. (Most Angelenos with Medi-Cal are enrolled in and will be able to continue with L.A. Care, a publicly operated plan.)

Mangia said the latest decision will still disrupt services for the 12,500 patients at St. John’s alone who will be forced to switch to Molina. He anticipates the clinic needing to hire more staff to help with patient navigation, but there’s no money for that.

“It was obviously an attempt to rectify the initial decision, but I’m not sure the impact on patients is going to be all that different. That’s my concern,” Mangia said. “It’s essentially an unfunded mandate.”

“Who’s the 50 percent that are going to be able to stay with Health Net and who are the 50 percent that are going to have to move?”

Jim Mangia, president and CEO of St. John’s Community Health

Health Net and Molina Healthcare did not reply to requests for comment, but in an early Tuesday morning call with investors, Molina CEO Joseph Zubretsky characterized the state’s final decision as “taking three steps forward, taking one step back” for the company, which had originally hoped to triple its Medi-Cal membership under the tentative award announced in August. 

In discussing the decision, Zubretsky and CFO Mark Keim alluded to closed-door negotiations between Molina, the state health care services department and the appealing insurers. When asked whether the state ever considered restarting the bidding process, Zubretsky said California regulators had “broad discretionary authority” to award contracts and new bids could have taken a significant amount of time. 

“With that as the understanding, we thought it best for the company, for membership and for investors to participate in the negotiation,” Zubretsky said.

Molina has agreed not to protest the final contract award and will subcontract with Health Net in Los Angeles County in the “negotiated settlement,” Zubretsky said. Molina will double its Medi-Cal membership — from 600,000 to 1.2 million — by 2024 as a result of this latest contract.

“We’ve agreed to the membership allocations that the state has now articulated in addition to waiving other types of legal rights that one would normally have,” Zubretsky told investors.

Community Health Group, the largest Medi-Cal provider in San Diego County, will also get a new contract in 2024. The insurer was excluded in the original summer announcement, but appealed the state’s decision. 

Community Health Group declined an interview request, but over the summer, the company’s chief operating officer, Joseph Garcia, told CalMatters that the state’s decision had been shocking because his company routinely outperformed other insurers. 

Zara Marselian, CEO of La Maestra Community Health Centers in San Diego, said the state’s new decision was a welcome surprise. La Maestra’s clinics serve low-income patients throughout the county and have worked with Community Health Group for nearly three decades. About 26% of its patients rely on Community Health Group for Medi-Cal, the most of any single patient group. Previously, Marselian had also predicted having to hire more staff to help patients navigate the transition.

“It’s really better for the Medi-Cal recipients that will not now have to transfer to another health plan and have their whole continuity of care disrupted,” Marselian said. “I’m really grateful however this happened. I’m really grateful on behalf of our patients.”

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MCOs; PayVider- JPM23: CVS weighs next steps in its primary care ambitions

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 may or may not buy up Oak Street Health to continue its march deeper down the PayVider path.

 
 

Clipped from: https://www.fiercehealthcare.com/payers/jpm23-cvs-health-still-weighing-next-steps-its-plans-foray-primary-care

 
 

SAN FRANCISCO—The top brass at CVS Health reiterated Tuesday that the healthcare giant is still plotting its move into primary care but emphasized that they want to ensure the next steps are the right ones.

CVS presented early on the second day of the J.P. Morgan Healthcare Conference as media reports circled that its primary care target could be Oak Street Health. Bloomberg reported that a $10 billion deal could be reached in weeks, citing people familiar with the negotiations.

However, Bloomberg’s sources did note that the ongoing talks between the companies could end without a deal in place.

For her part, CVS CEO Karen Lynch did not address the reported conversations with Oak Street Health. She said that while the company is still planning its push into primary care, it doesn’t want to act hastily.

“What we’ve been very clear about is we want to make sure it’s the right asset at the right time,” she said. “This isn’t a one-and-done.”

Lynch said during the company’s second-quarter earnings call in August that CVS was planning to get some kind of primary care deal on the books by the end of 2022. It reportedly courted and was rejected by concierge care provider One Medical, which is in the process of being bought out by Amazon.

Instead, it announced plans to acquire Signify Health, a move that instead enhances CVS’ capabilities in home health and value-based care.

The $8 billion deal is currently under regulatory review, and Lynch said the company expects it to close in the first half of 2023.

Signify’s strengths also align with key priorities at CVS, she said, as home health is the “future of healthcare,” and the company is aiming to make a greater push into enabling value-based care. A tightrope the company had to walk, though, is working with its competitors such as Humana that are also existing Signify clients.

Lynch said that as major insurers become increasingly diverse and vertically integrated, they’ve had to navigate the combination of direct competitors who are also clientele.

“As we think about the industry, we’re all kind of working with each other, and we’re all kind of customers of each other,” she said. “We’ve committed to them to be payer agnostic, and we think that’s how the industry will evolve over time.”

The Signify deal also brings with it Caravan Health, which is built to assist in establishing accountable care programs and was scooped up by Signify in early 2022. Lynch said Caravan’s capabilities will be critical to CVS’ ambitions in the provider space moving forward.

Chief Financial Officer Shawn Guertin added that the company’s plans around primary care also feed back into its focus on value-based care, as effective, accessible primary care is central to the care continuum.

“This is the first leg of the stool in our longer strategy,” Lynch said.

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FWA NC- Charlotte man convicted in multimillion-dollar Medicaid scheme

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]: Donald Booker stole $11M from NC using bogus drug testing and mental health services claims.

 
 

Clipped from: https://www.wfae.org/crime-justice/2023-01-11/charlotte-man-convicted-in-multimillion-dollar-medicaid-scheme

 
 

A jury convicted Charlotte man Donald Booker, 57, of federal charges in connection with a scheme that fraudulently took more than $11 million from the North Carolina Medicaid program, prosecutors said this week.

According to court filings and trial testimony, Booker was the owner of Diagnostic Laboratories, a urine toxicology testing laboratory, and United Youth Care Services, a company that provided mental health and substance abuse treatment services.

His co-defendant, Delores Jordan, pleaded guilty in December. Jordan owned housing provider Legacy Housing.

From January 2016 to August 2019, Booker and Jordan worked with others to defraud the NC Medicaid program, prosecutors said. They said Jordan enrolled vulnerable and Medicaid-income people for housing benefits and other services, and then referred them to Booker’s company for “medically unnecessary” urine screens and drug tests. Booker then paid kickbacks to Jordan and other co-conspirators in exchange for the business, prosecutors said.

 
 

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The jury convicted Booker of conspiracy to commit healthcare fraud, multiple violations of Anti Kickback Statute, money laundering conspiracy and money laundering.

Jordan pleaded guilty to healthcare fraud conspiracy and money laundering conspiracy.

Their sentencing dates have not been set.

The investigation was conducted by the FBI, IRS and NC Medicaid Investigations Division.

“I’m grateful to our federal and state partners for helping bring this person to account,” said Attorney General Josh Stein. “Medicaid resources belong to the taxpayers, and we’ll hold accountable anyone who defrauds the program.”

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