Category: MM Curator

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Senior Business Analyst (Medicaid Programs), Honolulu, Hawaii

 
 

Job Summary

Ensures that the contractual, regulatory, and accreditation requirements and objectives of HMSA’s Medicaid Programs are identified and met. Responsible for assisting with and supporting the development, implementation, planning, and oversight of activities related to Medicaid program requirements and objectives as assigned under the direction of the Director, Medicaid Administration and Sr. Manager, Government Programs.

Responsible for assisting with communication and coordination with HMSA departments, subsidiaries, and business associates that support Medicaid Program requirements and objectives and also for participating in the evaluation of their performance. Also responsible for assisting with the management of projects related to enhancing existing capabilities or developing new capabilities for the Medicaid line of business and analysis of business information with emphasis on the identification, development, and use of appropriate data and analytical methods for answering specific business questions related to HMSA’s Medicaid Programs.

Minimum Qualifications

 

  1. Bachelor’s (BA) degree and four (4) years of related work experience; or an equivalent combination of education and related work experience.
  2. Effective verbal and written communication skills
  3. Demonstrated knowledge of the operation of managed care programs.
  4. Demonstrated knowledge of Hawaii’s QUEST program or other governmental managed care programs.
  5. Intermediate knowledge of Microsoft Office applications. Including but not limited to Word, Excel, Outlook, and Power Point.

Duties and Responsibilities

Business Solution Development:

  • Develop, maintain and coordinate department user requirements, data reporting and application requirements for projects that affect Medicaid Programs.
  • Assist with solution design and development.
  • Participate in and lead teams involved in projects that affect Medicaid programs and collaborate with project leads and team members from other departments.
  • Communicate and collaborate with appropriate staff to ensure suitability of solutions. Develop effective use of advanced analytical methods and tools to enhance the delivery of solutions to meet business requirements. As required, learn new business concepts and methods applicable to Medicaid Programs projects and initiatives.

Business Project Analysis:

  • Develop and apply appropriate analytical methods to assigned business projects and tasks.
  • Thoroughly document all aspects of project requirements, methodology, task schedule, and analytical results including interpretation of results, summary findings, and presentation reports.
  • Collaborate with staff and management in own and other departments as required to fully understand business scope, business constraints, and business implications of analytical results

Program Management:In support of and with assistance from the Director and Sr. Manager, assist with:

  • Developing and communicating overall project strategy to ensure that business requirements are fulfilled across all Medicaid Programs activities and projects.
  • Ensuring that all Medicaid Program required reports, data, and activities are completed and delivered accurately and on time. Managing all aspects of the planning, execution, and closure of such projects.
  • Evaluating and directing the development of best practices, project standards, procedures, and quality objectives utilizing established project standards, procedures, and quality objectives.
  • Conducting project kickoff meetings and communicating individual roles and project/program expectations and responsibilities to ensure that all project team members have the tools and training to perform effectively.
  • Providing leadership to project managers, project and business leads, and other staff who are assigned to work on Medicaid Programs activities and projects.
  • Developing and maintaining collaborative relationships with Project Stakeholders, Business Relationship Managers, Project Office Managers, and other management and staff as necessary to provide oversight on Medicaid Programs activities and projects.
  • Identifying and analyzing business needs.
  • Translating business needs into appropriate and effective solutions.
  • Monitoring the design and implementation of solutions.
  • Establishing project baselines and developing project schedules.
  • Monitoring project milestones, timelines, technical deliverables, resource usage, critical dates, scope, costs, and quality to identify potential risks.
  • Identifying and tracking project issues and resolutions.
  • Facilitating the resolution of schedule and project related issues.
  • Assessing variance from project plans and implement measures to ensure projects remain within scope, time, cost, and quality objectives.
  • Tracking and reporting project status.
  • Preparing and presenting project updates to senior management and Executive Steering Committees.
  • Preparing and presenting business justification for tactical business priorities as required.
  • Facilitating the evaluation, selection, and contract negotiations for external vendors.
  • Managing vendor relationships in support of project goals.
  • Acting as a liaison between Medicaid Programs department, other HMSA Departments, subcontractors, and vendors.
  • Continuously providing constructive team feedback as is pertinent to Medicaid Programs projects.
  • Integrating, wherever possible, areas of improvement into the project lifecycle.
  • Coaching and mentoring less experienced department personnel.
  • Maintaining content of project websites to facilitate effective communication.

Studies and Reports:

  • Produce concise, structured, and informative data analytic reports summarizing projects, objectives, methods findings of program significance.
  • Document issues, background, data, methods, problems and alternatives, and results.

Other Duties/Functions:

  • Perform all other miscellaneous responsibilities and duties as assigned or directed.

Clipped from: https://jobs.wric.com/jobs/senior-business-analyst-medicaid-programs-honolulu-hawaii/683131783-2/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Program Manager – NY Medicaid Job – Elevance Health

 
 

Location: Company:

Eller, NC

elevance health

 
 

Program Manager – NY Medicaid
– Job Family: Business Support
– Type: Full time
– Date Posted:Aug 10, 2022
– Req #: JR12563
Location:
– New York, New York
– North Carolina, North Carolina
– New Jersey, New Jersey
– Florida, Florida
– Virginia, Virginia
Description
LOCATION: This is a remote from home opportunity. Occasional visits to an Elevance Health office may be required. Residency on the east coast is strongly preferred.
HOURS: General business hours, Monday through Friday.
.
The Program Manager for delegated risk is responsible for the ongoing operational management and oversight of NY GBD delegated risk programs SOMOS and CAIPA. Responsible for the development and ongoing management of one or more multi-year external client facing programs within a business unit. Program managers typically support business strategies through an integrated portfolio of external client facing projects or initiatives. A program manager may have responsibility for a piece of a larger enterprise/regional external client facing program.
.
Primary duties may include, but are not limited to:
– Manages and coordinates the development, approval, implementation and compliance of on-going external client facing programs; develops program budget; ensures program meets its stated objectives; provides subject matter expertise in response to day to day external client facing business issues.
– Researches applicable subject matter practices and remains aware of industry trends.
– Manages external client facing relationships and partners with corporate and regional business areas.
– Coordinates training related to external client facing program; develops program success measures and performs periodic assessments of program success.
.
Required Qualifications
– Requires a BA/BS and minimum of 5 years external client facing experience in program/project management; or any combination of education and experience, which would provide an equivalent background.
.
Preferred Qualifications
– Graduate degree preferred.
– Project management certification preferred.
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealthinc.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ab*****@*********lp.com for assistance.
EEO is the Law
Equal Opportunity Employer / Disability / Veteran
Please use the links below to review statements of protection from discrimination under Federal law for job applicants and employees.
– EEO Policy Statement
– EEO is the Law Postero
– EEO Poster Supplement-English Version
– Pay Transparency
– Privacy Notice for California Residents
Elevance Health, Inc. is an E-verify Employer
Need Assistance?
Email us (el************@*********lp.com) or call 1-877-204-7664

 
 

Clipped from: https://www.adzuna.com/details/3395128555?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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RN, Manager, Utilization Management Nursing (Louisiana Medicaid) Job in Coushatta, LA at 004 Humana Insurance Company

 
 

Description

Humana Healthy Horizons in Louisiana is seeking a Manager, Utilization Management Nursing who will utilize clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Manager, Utilization Management Nursing applies a Person-Centered approach, works within specific guidelines and procedures; applies advanced technical knowledge and clinical criteria to solve moderately complex problems; receives assignments in the form of team and/or department goals and objectives and determines approach, resources, schedules and monitors success of appropriate team or department goals.

Responsibilities

Essential Functions and Responsibilities

  • Supervise utilization management personnel and oversee all utilization management functions, including inpatient admissions, concurrent review, prior authorization and referrals to care management.
  • Oversee, monitor, orient and train staff in the use of standard utilization management criteria including MCG, Interqual, and ASAM.
  • Lead development of utilization management policies and procedures to ensure compliance with state and federal requirements and incorporate industry best practices.
  • Collaborate with internal departments, providers, and community partners to support the delivery of high-quality utilization management services, including introducing innovative approaches to utilization management.
  • Monitor and maintain staffing levels to meet care and service quality objectives.
  • Conduct timely evaluations of direct reports and provide regular opportunities for professional development.
  • Influence and assist corporate leadership in strategic planning to improve effectiveness of utilization management programs.
  • Collect and analyze performance reports on utilization management functions to monitor adherence with benchmarks, identify opportunities for process improvement, and develop recommendations to leadership.
  • Conducts briefings and area meetings; maintains frequent contact with other managers across the department and the company.

               
 

Required Qualifications

  • Licensed Registered Nurse (RN) in the state of Louisiana with no disciplinary action.
  • Must reside in the state of Louisiana.
  • Previous experience in utilization management.
  • Two (2) or more years of clinical experience preferably in an acute care, skilled or rehabilitation clinical setting.
  • Two (2) years of leadership experience.
  • Knowledge of Interqual, ASAM and/orMilliman (MCG) criteria.
  • Comprehensive knowledge of Microsoft Office applications including Word, Excel, and Outlook.
  • Ability to work independently under general instructions and with a team.
  • Must have the ability to provide a high speed DSL or cable modem for a home office.
  • A minimum standard speed for optimal performance of 25×10 (25mpbs download x 10mpbs upload) is required.
  • Satellite and Wireless Internet service is NOT allowed for this role.
  • A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
  • Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.

Preferred Qualifications.

  • BSN, Bachelor’s degree in health services, healthcare administration, or related field.
  • Experience working with Medicaid and/or health plan Utilization Management.
  • Possess subject matter expertise in review of inpatient admission and concurrent reviews requests.
  • Experience managing staff who review and process prior authorization, inpatient admission reviews and concurrent reviews.
  • Experience serving Medicaid, TANF, and/or CHIP populations.

Additional Information.

  • Workstyle: Remote with limited travel.
  • Travel: Up to 10% to Humana Healthy Horizons locations in Metairie or Baton Rouge, LA
  • Typical Work Days/Hours: Monday – Friday; 8:00am – 5:00pm CST with potential rotating on-call schedule.
  • Direct Reports: up to 12 Associates.

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40

 
 

Clipped from: https://www.ziprecruiter.com/c/004-Humana-Insurance-Company/Job/RN,-Manager,-Utilization-Management-Nursing-(Louisiana-Medicaid)/-in-Coushatta,LA?jid=d7f30fc7264936e6&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Medicaid Biller, South Jordan, Utah

 
 

Overview


 

Avalon Health Care Management, Inc. is seeking an experienced Medical Biller for a Medicaid Commercial/Hospice Biller!

The general purpose of the Medicaid Biller is processing and collections of billing Utah, Washington, Arizona, Hawaii, and California Medicaid and Hospice Programs. Includes billing State and Medicaid HMO programs.

If you seek to use your mind and your heart to improve lives on a daily basis, come join our team! We offer great challenges, a rewarding career and opportunities for advancement!

Our Benefits include:

  • Medical, Dental, Life, Vision, Short Term Disability, Long Term Disability, and Pet insurance.
  • We offer career advancement courses
  • Two weeks of PTO
  • 401K

Responsibilities


 

  • Review and follow up with the facilities to ensure facility has received authorization to provide services to Medicaid and Hospice patient. Review the TARS, 10A, Award Letters, Managed Medicaid Authorizations.
  • Ensure all rates are correct within the billing software. Entry of new Medicaid rates as they are published within the various states.
  • Employee will bill according to the outlined billing schedule as set by the Avalon Corporate Office. Billers will prepare, review, and transmit claims using billing software through electronic and paper claim processing.
  • Employee will provide claim follow up based on Avalon claim review protocol. Biller will contact Medicaid providers through phone and on-line review of outstanding claims. Follow up process will continue until claims in reduce from outstanding AR. 
  • Outstanding claims will be researched and reviewed until the AR payer has been relieved. Employee will process refunds and adjustments according to Avalon guidelines.
  • Employee will collect the payment EOB and process payment as indicated for patients’ dates of service. Payments which are not equal to outstanding AR will be researched and reprocess for refunds, additional payment request, or adjustment needs.
  • Employee will need to have effective communication with the Medicaid and Hospice payers to resolve outstanding issues. Employee will also need to work effectively with facility personal to resolve issues for billing.
  • Data entry of ancillary charges within the billing software for month end close.
  • Completes monthly aging for facilities and attends aging review meetings when necessary.
  • Update cash spreadsheet for Cash Management Department.
  • Run collection reports for Cash Management and Operational requests.

Qualifications


 

  • Associates Degree or equivalent work experience.
  • Basic understanding of computer technology.
  • Proficient in Excel. 
  • Knowledge of and previous experience with payroll taxes and quarter and year-end adjustments.
  • Minimum of 2 years of billing experience.

Avalon Health Care Group is an Equal Opportunity Employer.

#CB

#Talroo

 
 

Clipped from: https://jobs.krqe.com/jobs/medicaid-biller-south-jordan-utah/684060971-2/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Massachusetts Suit Over Circumcision Medicaid Payments Fails

MM Curator summary

[MM Curator Summary]: Low income families will still have access to circumcision services, much to the chagrin of far left wing anti-circumcision extremists.

 
 

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.

 
 

Several Massachusetts taxpayers lost a lawsuit to prohibit the state’s Medicaid agency from paying for neonatal male circumcisions, because they have no actionable claim under either federal or state law, a state appeals court said.

Private citizens don’t have a right to enforce a state regulation precluding MassHealth from paying for services that aren’t medically necessary, because the decision of what constitutes a medically necessary service is committed to the agency’s discretion, the Massachusetts Court of Appeals said.

The plaintiffs alleged that most circumcisions aren’t medically necessary and usually are done at the request of the parents for cultural or …

 
 

Clipped from: https://news.bloomberglaw.com/health-law-and-business/massachusetts-suit-over-circumcision-medicaid-payments-fails

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Nebraska Medicaid Announces Requests for Proposal For New Health Insurance Contracts

MM Curator summary

[MM Curator Summary]: Awards are currently expected late August.

 
 

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.

 
 

LINCOLN — The Nebraska Department of Health and Human Services (DHHS) has received bids from five health plans to provide healthcare services for its Medicaid managed care program. A request for proposals (RFP) was initially posted in April 2022, and bids were due July 1.

The five bidding companies are:

• Community Care Plan of Nebraska, Inc. d/b/a Healthy Blue

• Medica Community Health Plan

• Molina Healthcare of Nebraska, Inc.

• Nebraska Total Care, Inc.

 
 

• UnitedHealth Care of the Midlands, Inc.

Of the named bidders, Nebraska Medicaid will select two to three to provide physical health, behavioral health, pharmacy, and dental services. The chosen bidders will be contracted with DHHS for at least five years to provide most healthcare services to the members in managed care.

Nebraska Medicaid plans to announce the winning bidders in late August. From now until then, the bids will be scored based on specific and general expertise by Medicaid leaders. The State answered two rounds of bidders’ questions prior to the due date.

The bidders will be evaluated based on criteria through their proposals, which may include oral interviews, as part of the multi-stage process. The companies bring forward action plans and discuss their past learning experiences. From there, Medicaid will determine which are best suited to provide the best service to our members and providers over the next several years.

“Our goal throughout this RFP has been to improve our members’ and providers’ experience by building on previous successes and making thoughtful changes in response to stakeholder feedback,” Medicaid Director Kevin Bagley said. “That goal will be top of mind for our team as we rigorously evaluate these five proposals over the coming weeks.”

The new RFP includes several changes, integrating dental services with physical health, behavioral health, and pharmacy services; simplifying credentialing for providers; and improving electronic visit verification. After the winning bidders are chosen, Medicaid will work on implementing these changes as smoothly as possible for our members.

 
 

Clipped from: https://www.yankton.net/community/article_d1b96960-0c91-11ed-8f54-6bdccbfaa152.html

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INDIANA- Local businessman accused of medicaid fraud, counterfeiting

MM Curator summary

[MM Curator Summary]: Timothy Adkins may or may not have forged doctor’s signatures thousands of times, depending on whether or not you believe the docs whose signature are in question. He’s facing about $950,000 of fraud allegations.

 
 

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.

 
 

 
 

Timothy Dwain Adkins

HANCOCK COUNTY — A six-year investigation by officials with the Family and Social Services Administration (FSSA) concluded a local man committed medicaid fraud and counterfeiting, resulting in the misuse of thousands of state dollars.

The case is being prosecuted by officials from the Attorney General’s office. It was officially opened in Hancock County Circuit Court last week under the supervision of Judge Scott Sirk.

Timothy Dwain Adkins, 66, 300 block of Shadow Creek Pass, Greenfield, has been charged with three Level 5 felony medicaid fraud charges and one Level 6 felony charge of counterfeiting from incidents in 2017 and 2018. The most serious charge carries up to six years in prison.

According to a probable cause affidavit, there is sufficient reason to believe Adkins committed medicaid fraud when he submitted claims to Indiana Medicaid stating doctors were the rendering Health Service Provider in Psychology (HSPPs) when they were not. Additionally, officials believe Adkins committed forgery in 67 instances where the signature of a doctor was signed on patient treatment plans.

The report states FSSA contacted the Medicaid Fraud Control Units (MFCU) and reported suspected fraudulent billing of in-home psychotherapy services, Behavior Source, LLC. Behavior Source is a provider of mental health services, owned by Adkins, who holds no psychology licenses or credentials.

According to the Better Business Bureau, the business was opened in Indianapolis 2012 with Adkins named as the business manager and director of operations. Behavior Source employs HSPPs and provides billing and HSPP oversight services to businesses who provide outpatient psychotherapy, the report states.

A doctor told officials he worked for Behavior Source as an HSPP until July 23, 2017. The doctor stated he did not see any patients of Behavior Source after July of 2017, contrary to billing data showing the rendering HSPP through May 2019.

A subsequent pull of billing data indicated billing was submitted by Behavior Source with the doctor listed as the rendering HSPP through March 8, 2021. In total, 12,472 claims were submitted to Indiana Medicaid totaling $475,116 where the doctor was listed as the rendering provider despite his statement he no longer worked for Behavior Source, the report states.

In March 2020, an investigator interviewed another doctor who said she was an HSPP for Behavior Source during two different time periods: first in 2016 or 2017 for approximately three or four months, and then starting again on August 12, 2019. Officials noted there were treatment plans which had her signature on them in 2018, but the doctor could not explain how her signature could be on the documents.

In September 2021, the MFCU sent a subpoena to Behavior Source for patient records to conduct a random sample audit of 23,812 claims submitted to Indiana Medicaid by Behavior Source from Jan. 1, 2017 to Aug. 20, 2021.

The report states a review showed a 60.30% error rate — meaning the percentage of the reviewed claims and patient records did not meet the program requirements necessary for reimbursement from Indiana Medicaid — because patient treatment plans were not signed by a physician or HSPP noting the HSPP signatures were forged, or the dates of review exceeded the regulatory requirements.

The fraudulent billing for non-compliant services equates to an actual over-payment of $12,936.63 and an extrapolated value to the total claims of $947,837.03, the report states.

Adkins was interviewed by investigators in February. Adkins told officials he was not surprised by the error rate and said he shared the concern of treatment plans not having HSPP signatures, the report states.

Adkins said, depending on the date, faxes from one doctor did not always come in on a regular basis. Adkins said the ability of therapists to get documentation back to him with HSPP signatures was “spotty,” the report states.

Adkins told officials one of the doctors would not sign the vast majority of the treatment plans submitted to him by therapists because the doctor wanted more definition in specific areas of the treatment plan. Adkins said this put him into a considerable “panic” because Behavior Source had just signed contracts with additional school districts and had therapists depending on HSPP approval from Behavior Source, the report states.

Adkins said he knew it was “messed up,” the report said, but he didn’t want to stop services to over 500 kids, 40 therapists and schools who would have no services. Adkins said he set aside money to pay back Indiana Medicaid and said, “I’ll fall on the sword if need be,” the report states.

According to the report, Adkins agreed that he was not providing services at the level they were required to be provided by Medicaid, as he was not having proper HSPP oversight of mid-level providers.

When asked about one doctor’s signatures on 67 documents, from January 2017 through August 2019, Adkins told officials in the report there was never a time the doctor’s signature was on paperwork for Behavior Source when she did not work for Behavior Source.

Adkins admitted his normal procedure during the doctor’s employment was to electronically cut out a signature, paste it on the document and send the pre-signed document to the doctor.

Adkins stated he did this so he wouldn’t need to meet with doctor in person, the report states. When officials interviewed the doctor, the doctor said her process was to always sign documents in pen. When asked if the doctor had ever received pre-signed documents from Adkins for review, she emphatically denied that ever happened, the report said.

When analyzing the billing data submitted to Indiana Medicaid by Behavior Source from January 2018, to August 2019 officials say where some 4,679 claims, totaling $92,650, were submitted to Indiana Medicaid where the doctor was listed as the rendering provider despite her statement she did not work for Behavior Source during this period and did not sign or authorize any documents.

Adkins made his initial appearance in Circuit Court late Friday when he was officially arrested. No bond amount was listed, however he is not an inmate in the county jail. Adkins is slated to be back in court in late September for a pretrial conference.

 
 

Clipped from: https://www.greenfieldreporter.com/2022/07/26/local-businessman-accused-of-medicaid-fraud-counterfeiting/

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Patient-level factors influencing adherence to follow-up imaging recommendations

 
 

MM Curator summary

[MM Curator Summary]: Even after accounting for all other person-level variables, Medicaid members still don’t complete ordered imaging followups.

 
 

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.

 
 

 
 

Purpose

To determine which, if any, patient-level factors were associated with differences in completion of follow-up imaging recommendations at a tertiary academic medical center.

Methods

In this IRB-approved, retrospective cohort study, approximately one month of imaging recommendations were reviewed from 2017 at a single academic institution that contained key words recommending follow-up imaging. Age, gender, race/ethnicity, insurance, smoking history, primary language, BMI, and home address were recorded via chart extraction. Home addresses were geocoded to Census Block Groups and assigned to a quintile of neighborhood socioeconomic status. A multivariate logistic regression model was used to evaluate each predictor variable with significance set to p = 0.05.

Results

A total of 13,421 imaging reports that included additional follow-up recommendations were identified. Of the 1013 included reports that recommended follow-up, 350 recommended additional imaging and were analyzed. Three hundred eight (88.00%) had corresponding follow-up imaging present and the insurance payor was known for 266 (86.36%) patients: 146 (47.40%) had commercial insurance, 35 (11.36%) had Medicaid, and 85 (27.60%) had Medicare. Patients with Medicaid had over four times lower odds of completing follow-up imaging compared to patients with commercial insurance (OR 0.24, 95% CI 0.06–0.88, p = 0.032). Age, gender, race/ethnicity, smoking history, primary language, BMI, and neighborhood socioeconomic status were not independently associated with differences in follow-up imaging completion.

Conclusion

Patients with Medicaid had decreased odds of completing follow-up imaging recommendations compared to patients with commercial insurance.

 
 

Clipped from: https://www.clinicalimaging.org/article/S0899-7071(22)00184-X/fulltext

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GDIT Wins $65 Million Medicare and Medicaid Cloud and Data Integration Contract

MM Curator summary

[MM Curator Summary]: The award will be to implement a data warehouse that includes claims and member data for Medicare and Medicaid programs.

 
 

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.

 
 

 
 

Government Technology and Services Coalition member and mentor partner General Dynamics Information Technology (GDIT), a business unit of General Dynamics, has been awarded a new $65 million contract by the Centers for Medicare & Medicaid Services (CMS) Enterprise Architecture Data Group to support its Integrated Data Repository (IDR). The five-year contract has a one-year base period, three one-year and one eight-month option periods, and one four-month transition period.

CMS maintains the largest volume of healthcare data files in the world. The IDR is a high-volume data warehouse integrating claims, beneficiary and provider data sources to support various Medicare and Medicaid programs. Access to this robust integrated data supports analytics across CMS, including insights into medical trends, healthcare costs, and fraud, waste and abuse.

Under this contract, GDIT will provide agile transformation and development, security and operations services in support of on-premise and cloud systems. GDIT will support the migration to the cloud and provide operations and maintenance services on both systems.

“CMS has made incredible progress as it moves its enterprise systems to the cloud,” said Kamal Narang, vice president and general manager for GDIT’s Federal Health sector. “This is another step in improving the agency’s data accessibility and analysis capabilities. As one of the largest providers of cloud services to CMS, we are proud to continue providing our cloud expertise to support their modernization journey.”

The contract continues GDIT’s 40-year partnership with CMS. In September 2020, CMS selected GDIT to evolve one of the largest public clouds in the federal government. Under that task order, GDIT is supporting the agency to help optimize its cloud technology investments and financial operations as it implements a mature multi-cloud environment designed to deliver critical healthcare services to tens of millions of Americans through hosted sites, Medicare.gov and Healthcare.gov.

Read more at GDIT

 
 

Clipped from: https://www.hstoday.us/industry/industry-news/gdit-wins-65-million-medicare-and-medicaid-cloud-and-data-integration-contract/

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New York Office of Medicaid Inspector General Proposes Regulations on Medicaid Provider Compliance Programs

MM Curator summary

[MM Curator Summary]: If the OIG has its way, MCOs will be added to the list of groups who have to prove they are dealing with fraud, waste and abuse.

 
 

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.

 
 

The New York State Office of Medicaid Inspector General (OMIG) published proposed regulations in the July 13, 2022 issue of the New York State Register.  The proposed regulations would repeal the current Part 521 – Provider Compliance Programs of Title 18 of the New York Codes, Rules and Regulations (NYCRR) in its entirety and establish new requirements for providers to detect and prevent fraud, waste and abuse in the Medicaid Program under a new Part 521: Fraud, Waste, and Abuse Prevention (Part 521). Part 521 would implement provisions of the New York State Fiscal Year 2020-2021 Enacted Budget and recommendations from the Department of Health’s Medicaid Redesign Team II. 

If enacted, the proposed rules would implement changes related to Medicaid provider compliance programs, Medicaid managed care organization (MCO) fraud, waste, and abuse prevention, and Medicaid providers’ “obligation to report, return, and explain Medicaid overpayments through OMIG’s Self-Disclosure Program.”  We have highlighted below certain provisions from the first of Part 521’s three subparts, Subpart 521-1, that are relevant to New York Medicaid providers as they structure and update their compliance programs.

Scope and Applicability of Program – Section 521-1.1

These proposed regulations require certain “Required Providers” (defined below) participating in the Medical Assistance program (Medicaid) to adopt a compliance plan to detect and prevent fraud, waste, and abuse in the Medicaid program. The following are deemed Required Providers and are obligated to comply with this proposed regulation:

  • hospitals, nursing homes, residential care facilities, and home care service agencies;
  • family care homes and residential treatment facilities for children and youth;
  • any managed care provider or managed long term care plan; and
  • any other person for whom the Medicaid program is or is reasonably expected to be a “substantial portion of their business operations.”  “Substantial portion of their business operations” includes persons who have claimed or received at least $1,000,000 a year from the Medicaid program. The current statutory definition sets $500,000 as the threshold.

In the current regulations, managed care providers and managed long term plans are not included in the scope of the Required Provider definition. 

Duties of Required Providers – Section 521-1.3(a)

To receive payment through the Medicaid program, Required Providers must maintain a compliance program. The regulations define an “effective compliance program” as a program that is:

  • well-integrated into the company’s operations and supported by the highest levels of the organization;
  • promotes adherence to the Required Provider’s legal and ethical obligations;
  • and is designed and implemented to prevent, detect, and correct non-compliance with Medicaid program requirements, such as fraud, waste, and abuse.

The provider must ensure that contracts with contractors, agents, subcontractors, and independent contractors are subject to their compliance program, and if such individuals meet the definition of an Affected Individual, the contracts must include termination provisions for failure to adhere to the Required Provider’s compliance program requirements. The proposed regulations define Affected Individuals as “persons who are affected by the Required Provider’s risk areas including the Required Provider’s employees, the chief executive and other senior administrators, managers, contractors, agents, subcontractors, independent contractors, and governing body and corporate officers.”

Risk Areas for Providers and Medicaid MCOs – Section 521-1.3(d)

The proposed regulations indicate there are ten risk areas, defined as areas of operation affected by the compliance program, that the compliance program must apply to:

  • billings;
  • payments;
  • ordered services;
  • medical necessity;
  • quality of care;
  • governance;
  • mandatory reporting;
  • credentialing;
  • contractor, subcontractor, agent, or independent contract oversight; and
  • other risk areas that are or should reasonably be identified by the provider through “organizational experience.” 

The regulations define “organizational experience” to include four components, which include the Required Provider’s knowledge, skill, practice, and understanding in operating a compliance program; identification of issues or risk areas; experience, knowledge, skill, practice and understanding of its participation in the Medicaid program; and awareness of issues it should reasonably become aware of for its services.

In the current regulations, “ordered services” and “contractor, subcontractor, agent, or independent contractor oversight” are not risk areas that were are required to be addressed in a Required Provider’s compliance program. The proposed regulations also add ten additional risk areas for Medicaid MCOs, which must also be addressed in their compliance programs.  These additional areas of risk include:

  • Compliance with Medicaid MCO’s contract terms;
  • Cost reporting;
  • Submission of encounter data;
  • Network adequacy and contracting;
  • Provider and subcontractor oversight;
  • Underutilization;
  • Marketing;
  • Provision of medically necessary services;
  • Payments and claims processing; and
  • Statistically valid services verification.

Certification – Section 521-1.3(f)

Required Providers must submit an annual certification to the Department of Social Services that it maintains a compliance program.  The Required Provider must also submit a copy of such certification to each Medicaid MCO with which the Required Provider has a provider agreement.

Written Policies of Compliance Program – Section 521-1.4(a)

Required Providers are required to have written policies, procedures, and standards of conduct that govern the compliance program. These policies, procedures, and standards of conduct must cover several topics, including providing guidance on dealing with compliance issues, descriptions of how compliance issues are investigated and resolved, and include a policy of non-intimidation and non-retaliation for good faith participation in the compliance program. The policies and procedures must be reviewed at least annually.

Compliance Officer and Compliance Committee – Section 521-1.4(b)-(c)

In the current regulations, a Required Provider was responsible for designating one employee that is responsible for the compliance program’s operation.  Now, under the proposed regulations, Required Providers must designate a compliance officer who will oversee, monitor, and review the compliance program, implement compliance work plans, and investigate matters related to the compliance program. The compliance officer will also coordinate with a designated compliance committee. The compliance committee will be responsible for, among other things, collaborating with the compliance officer on written policies and procedures, ensuring that the compliance officer is allotted sufficient resources to perform their job, and enacting required modifications to the compliance program.

Compliance Training and Education – Section 521-1.4(d) 

Required Providers must maintain a compliance training and education program for the compliance officer and all Affected Individuals.  This training must be completed at least annually. The training and education must include, at a minimum, a discussion of the following:

  • risk areas and organizational experience of the Required Provider;
  • written policies, procedures, and standards of conduct related to compliance;
  • the role of the compliance officer and compliance committee;
  • the obligation of Affected Individuals to report compliance concerns, the procedures for reporting concerns, and the non-intimidation and retaliation policies of the Required Provider;
  • disciplinary standards related to the compliance program and fraud, waste, and abuse prevention;
  • corrective action plans and response to compliance issues;
  • Medicaid program requirements and the Required Provider’s category of services;
  • coding and billing requirements and best practices;
  • claim development and submission; and
  • for Medicaid MCOs only, the fraud, waste, and abuse prevention program requirements of Subpart 521-2 (which will be further discussed in a future Mintz blog post).

OMIG Compliance Program Reviews – Section 521-1.5 

OMIG may review a Required Provider’s compliance program to determine its compliance with the regulations. OMIG will notify a Required Provider of its intent to commence a review, and such notice will include the review period and procedures that will be undertaken to complete the review.  Once the review is complete, OMIG will advise the Required Provider if it satisfies the requirements of Part 521 and if any deficiencies need to be corrected.

Conclusion

If enacted, Part 521-1 will compel Medicaid providers and Medicaid MCOs to examine and, potentially, restructure their compliance programs. OMIG is accepting public comment on these proposed regulations through September 11, 2022.

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Clipped from: https://www.mintz.com/insights-center/viewpoints/2146/2022-07-26-new-york-office-medicaid-inspector-general-proposes