Tag: Medicaid

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/37Tb3lU (bonus- http://bit.ly/3a5us4U)

For optimist readers- http://bit.ly/2R8eyOK

We made it to 2020. Where are the flying cars?

THIS ONE GOES UP TO 11! Come hang out at the 11th annual Medicaid Innovations Conference in Orlando in February. One of my favorite events (it must be- I’ve been to all but 1 of them over the years). Check out the agenda and sign up here- https://www.medicaidinnovations.com/agenda.html

ANDY, ANDY- SO FINE AND DANDY- HOW DOES YOUR BUDGET GROW? Continuing our coverage of the Good Guvn’r Cuomo’s Adventures in Bad Leadership this week. Andy announced a 1% cut to Medicaid providers on New Year’s Eve (Happy New Years, Suckers!). That cut will be for 90 days and will save about $126M. Sounds cool until you realize that just the Medicaid budget hole is $4B. Andy also promised a plan to deal with the overall deficit back in December. Part of that plan appears to be cooking the books again by delaying about $1.7B in Medicaid payments so that they appear in the next FY (He also did this last year, but secretly). We all wait with baited (bated?) breath for the new plan. Especially officials (and taxpayers) in the counties of NY. Cuomo’s recent state of the state hinted at increasing the share counties chip in to cover the costs of unfettered Medicaid spending. Innovation abounds in the legislature as well: the brilliant Dems in the statehouse want to “address the deficit” but without “cutting services.” I would also like to lose weight by eating cookies. Idiots.

NEW WAY TO GET A DO-OVER ON AN MCO BID? ELECT A NEW GOVERNOR, OF COURSE- If you lost out on the latest KY bids, dust off your proposal. Beshear- in his effort to undo all things Bevin- has ordered a do-over on the latest contract awards. Is that even legal? Is “legal” even a thing anymore?

MOLINA BACK ON THE WARPATH- The MCO will purchase NextLevel Health for about $50M. The buy will give Molina a strategic path to increase Illinois Medicaid revenues.

CMS TINKERING WITH 340B AGAIN- This time CMS is taking aim at duplicate discounts (that hurt Rx makers by hitting them with having to pay discounts in both 340B and the Medicaid Drug Rebate Program; MDRP). The federalis released a guidance bulletin Jan 8, outlining what The Big House views as best practices. Basically, the recommendations focus on using data to avoid overlaps, writing better contracts and limiting covered entities. Initial opposition was summarized as thus: These are great ideas, but it will make it harder for us to keep the federal money flowing. Doing the right thing is too costly.

YOU HAVE A FEW MORE WEEKS TO TELL CMS HOW MUCH YOU HATE CHANGES TO SUPPLEMENTAL PAYMENTS REGS (BUT DON’T MAKE IT TOO OBVIOUS HOW SELF-INTERESTED YOUR OPPOSITION IS)- I think the gist is best gleaned from a recent quote by CMS Administrator Veerma: “We have seen a proliferation of payment arrangements that mask or circumvent the rules where shady recycling schemes drive up taxpayer costs and pervert the system.” Supplemental payments to skilled nursing (and other) facilities now account for $3.5B each year (about 7% of all Medicaid FFS spend)- but when these payments are passed through the managed care model, CMS has very little idea what they are actually paying for.  Feb 1 is the deadline to weigh in on the proposed rule. The rule establishes new reporting requirements about what states are doing with the payments.

KANSAS HOPS ON THE EXPANSION TRAIN- The Good Guvn’r Kelly announced plans to take the free federal money last Thursday. The Kansas expansion plan will seek to get additional funding for services for the thousands of severely disabled members who have been on the waiting list for years. Just kidding – I am sure it will all go to comparatively healthy 20-year olds who don’t want to be forced to work to pay for their own “coverage.” To be fair to KS, they have cleared their waiting list in the past. Not all states (and certainly not expansion ones) can say the same thing.

$2.6B IN 2019 FRAUD RECOVERIES LAUDED BY DOJ. SOUNDS GREAT UNTIL YOU REALIZE CONSERVATIVE ESTIMATES PUT CARE/CAID FRAUD AROUND $100B EACH YEAR- Read the latest annual report here. It is getting better. Long way to go. Very long way.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award.  Just a few tidbits this week, dear readers (it is just the first full week of the year, after all). Lets first go to Balmore (Baltimore), where we find someone murdered over Medicaid fraud. This one doesn’t have a dollar amount, but I wanted to share it with you to show you how pernicious and evil Medicaid fraud is. Latrina Ashburne, a teacher’s aide, was murdered (allegedly) by Devon Carter and Clifton Mosby. The broke into her home and shot her, thinking she was a Medicaid fraud whistleblower in a case against a friend of theirs.  Lets head north for some less lethal Medicaid fraud. In Danville, New Hampshire we find Richard Gaudette. Mr. Gaudette was sentenced for stealing $111k in Medicaid bucks using a personal care services scheme. He billed for services even when his clients were in the hospital or dead. For our last entry this week, let’s head west, way west- all the way on over to Alaska. We find John Zipperer in Wasilla, where he operated a $9M scam using unnecessary tests. He ran over 1M (or claimed he did) tests on urine samples using a lab he owned in Tennessee. His $9M scam was 10x the total amount that all other providers in Alaska were reimbursed for the same tests. Wow. John Z- you win this week’s award! Taxpayers, you of course lost, yet again.

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (finally get those leaves up if you haven’t. I know I haven’t. ) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com .

Trystero: پدر پسر را فرستاد تا دنیا را نجات دهد

Soundtrack for today’s RoundUp pessimist readers– http://bit.ly/34fvYO3 (kind of can’t believe this one has never made into the Roundup in all these years. Something we all need about now as we do our umpteenth Christmas party. I also used to do a solid Axl Rose impression in high school, with this one at the top of the set list)

For optimist readers- http://bit.ly/2LP0zvd (this song will grab your heart, and warm it like a wood fire. Or a cup of cider. Or the last hug you got from that lost loved one, when you didn’t know it would be the last one. It’s a REALLY good song, even though its basically sad).

THIS ONE GOES UP TO 11! Come hang out at the 11th annual Medicaid Innovations Conference in Orlando in February. One of my favorite events (it must be- I’ve been to all but 1 of them over the years). Check out the agenda and sign up here- https://www.medicaidinnovations.com/agenda.html

NOT SO FAST ANDY BOY- Stop1 in the Cuomo Medicaid Malarkey Tour: shady deals where you slide big ticket spending out of one fiscal year into another to hide Medicaid spending growth that exceeded the legal limit. Stop 2: pass a hospital gravy deal after they donate boucoup cash to the Democratic Party coffers. Stop 3: Go into damage control mode and do lots of provider cuts real quick-like to cover your tracks. Only problem is that the state Comptroller is on to your schemes, Andy. And he’s asking you to provide more info about the cuts you say will magically deal with the $4B over-run. Looks like maybe you actually got caught this time? Should we get a FISA warrant?

MOLINA JOINS BLUEGRASS STATE MCO ROSTER- Chalk up another win for a Medicaid plan that many thought was on the ropes this time last year. Molina 2.0 (this time with less Molinas) just won an MCO contract in KY. Go live is July 1, 2020. Congrats to all our friends and readers at Molina.

PASSPORT KICKED OFF HOME FIELD, WHAT NOW EVOLENT? But not so good news for longstanding KY MCO incumbent Passport. Passport lost out in the official agency review process. This one could get interesting though (seems each of the MCO awards have their own flavor of jacked-up these days)- the legislature is ticked because they were given the contracts after the award. And the incoming Governor Beshear (continuing the Beshear dynasty after a brief pause- his daddy was Governor 3 Guvs before) is also promising to review the contracts. So there may be some golf course opportunities the next few months. Or at least until July 1, 2020. This news is particularly troubling for Evolent who just sunk $70M into Passport to help the flailing plan meet financial solvency requirements going into the bid.

NEW YORK HAS HIGHEST NUMBER OF MEDICAID INELIGIBLES ON ROLLS– A new study out of George Mason U out estimates that as many as 3.3M working age adults have incomes too high to be eligible for Medicaid, but are enrolled anyway. This data point (enrollees who should not be enrolled based on income) increased 80% between 2012 and 2017. What else was going on then?

MEDICAID EXPANSION RATE CELLS MAY HAVE LED TO $75B IN OVERSPENDING- No one really cares though, because its free federal money. You know, paid by those federal taxpayers (not you of course, so nothing to see here. You don’t pay any federal taxes, right?). In a story related to the NY one above, other news items focused on the national impact of increasing the enrollment streamed to ACA/Expansion rate cells. Basically, the human behavior you would expect to happen happened in expansion states– pay 100% of costs for members in a certain (new) eligibility category, and states were not quite thorough in who they put in those buckets. If you took an Econ 101 class before the downgrade, this would have been covered in the lecture on moral hazard.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award.  We absolutely have to start with the Hoverboarding dentist. Seth Lookhart in Alaska was filmed extracting a tooth while riding a hoverboard. This idiot texted it to 8 people and it got passed around from there. His crimes? Not hoverboarding, but rather stealing $25k from Medicare and $10k from AK Medicaid with unnecessary procedures schemes. Technically he doesn’t meet our $50k threshold for the follies, but I just knew many readers would be sad if they did not learn of the Tale of the Hoverboarding Dentist.  Or as I like to call him – The Floating Filling Fixer. Let’s head back east to Vero Beach, FL where we find a pretty big ($1M) personal care attendant scheme. Marie Isaac was the latest to be charged, but there were 19 PCAs who falsified time sheets to get more Medicaid bucks. In Isaac’s case, she sometimes billed for 6 hours of service a day, but her patient testified she never was there more than 45 minutes. Slow fraud week this week folks. I guess fraudsters have tons of Christmas parties keeping them otherwise occupied, too.

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (get some good firewood if there’s any left in your area. Fires heal.) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com .

Trystero: Отець послав Сина, щоб спасти світ

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2Buu4Ni

For optimist readers- http://bit.ly/2BqY5h7

MICHIGAN MOVING PBMS TO THE DOGHOUSE- So it seems that all the news of spread pricing these last 2 years or so has made people a little skittish on PBMs. Michigan Medicaid announced plans to nix its PBMs starting December 21 (interesting start date). At that time the state will take over management of drug benefits and save an estimated $40M. The change comes about 6 months after the Michigan Pharmacists Association rallied behind reports of PBM pricing shenanigans, including some that showed the state overpaying PBMs by $64M.

KEYSTONE STATE MOVING TO SINGLE PDL– All 8 PA MCOs will start using a single preferred drug list Jan 1 2020. The change was triggered by high Hep-C costs as well as an effort to help providers managing care for members with multiple drug regimes. State officials think this will save about $85M each year. Here’s the kicker- the earlier MCOs analysis said it will cost the state $81M each year. If you’ve ever tried to follow Medicaid Rx math you know its all witchcraft, so its not surprising that the MCOs and state came up with entirely different numbers.

WONDERS NEVER CEASE: FEDERAL JUDGE STOPS REGULATIONS PROMULGATED UNDER NORMAL LEGAL PROCESS– I think I have seen this movie before. If you followed the drama of the Public Charge Rule the last few months, you probably knew this was where we would end up. The Trump Administration promulgated rules that would enforce existing law (that requires those asking for admission into the U.S. to prove they will not require safety net services or have someone who can cover their costs. Very similar to what I found out when I wanted to move to Scotland in the late 1990s). The proposed rule made it all the way through the established, legal process- until it was rejected by 2 judges (1 in the southern district of NY and 1 in CA) who decided the right thing to do was to continue to not enforce existing law. My high school civics class really misinformed me about how the three branches of government work.

IDAHO CONSIDERING MAGIC MONEY POOL TO PAY FOR VOTER-APPROVED EXPANSION- And it looks like they will find it hiding in county coffers. Committee leads tasked with passing the hat are eyeballing $10M in county funds that they think are now fair game for Medicaid (since those funds currently go to uncompensated care, and Medicaid will now cover that). My prediction – these funds will be bundled with the disappearing tobacco settlement funds and get matched with the federal magic money cover expansion costs for about 6 months. That will grease the skids needed to get the initial vote done. Then we will hear about a huge Medicaid budget shortfall about 8 or 9 months into the expansion.

MORE NEWS STORIES OF MEDICAID PAYING COSTS FOR DEAD PEOPLE- This week its Minnesota with an estimated $3.2M owed back to the feds. Out of 100 sample capitation payments, 95 had unallowable payments. You can guess the answer by now – that this was during a transition to a new eligibility system, and we promise the new one won’t do the silly things the old one did (see also LA).

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award. Our first fraudster hails from Conway, Arkansas: Karen Todd was popped this week for billing $600k in bogus optometrist claims for her husband (Karen is the office manager; hubby the optometrist). Let’s stay in the south a moment and head to Raleigh, NC where we find Pamela Faulkner. Pam buddied up with Renee Borunda to steal $213,927 in Medicaid bucks. How? Bogus behavioral health services claims. Southerners continue to be represented this week as we head to Nashvegas. There we find Michael Kestner, Brian Richey, Daniel Seely and Jonathan White stealing a cool $100k from Medicaid (they tried for $8.6M but came up short) and another $5.3M from Medicare and TriCare. Their scheme involved rev max and fraudulent claims at their pain clinic. Ok let’s leave the south and head to Texas (its different, I promise). Omar Cuate Canales of Rio Grande City  plead out this week to $385k in Medicaid thievery using his DME business. Now its time to head to the heartland. Tracy Wellendorf of Cedar Rapids, Iowa agreed to pay back the $1M he stole from Medicaid using medically unnecessary sinus surgeries. Wellendorf agreed to pay back the $1M as a double-dog promise he did nothing wrong, but we all know something smells funny here (get it? Smells funny? Sinus surgeries…). Mrs. Todd you win this week’s award. Congratulations! Maybe you and hubby can take a nice vacation somewhere? I wanted to give this to Mr. Wellendorf, but since he wrote a big check to get the state to pretend he did nothing wrong, and I don’t want to get sued- Mr. and Mrs. Todd win! Taxpayers, you lost about $7.4M in that last paragraph.

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (make your first fire of the year if its cold enough wherever you are) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: de Vader zond de Zoon om de wereld te redden

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/33w0dQN (this video from 1973 is amazing; and these guys are still touring)

For optimist readers- http://bit.ly/2MA1lvT

SUE TO GET RATES YOU WANT (WHERE DO I SIGN UP FOR THIS DEAL?)- Alaska “providers” (hospitals and nursing homes, for those fooled by this label. It ain’t Doc Brown making house calls) successfully used the judiciary to keep their pay rates above the law. The law being the process used to govern budgets in the state, including cuts. See, The Good Guvn’r Dunleavy vetoed (that’s a legal power executives have) about $50M in state Medicaid spending. So, the agency has to enact those cuts. Well, “providers” whose revenue streams depend on those Medicaid funds didn’t like it and got a judge to undo the legal process. I think I’ve seen this movie before, but in a different theater…

IOWA STILL LOOKING FOR 3^RD MCO- In case you missed it United submitted its Dear John letter earlier this year. The Medicaid Director commented this week on plans to issue an RFP for a replacement MCO, but no timetable is in place yet.

NH AND FEDS AT ODDS OVER SCHOOL BASED MEDICAID PROGRAM- The Good Guvn’r of The Granite State sent a re-assuring letter to school superintendents late September. Why? Because new CMS guidance looks to make sure only services covered under the state Medicaid plan can be paid for by Medicaid in schools. Someone tell me what I am missing, but can’t this just be fixed with a state plan amendment adding any outlier services into the covered mix? And does anyone have an estimate of how much Medicaid has paid for non-covered services in schools over the years?

GOOD GUVN’R CUOMO TAKING BRIBES IN UKRAINE? SORRY, IN NY– At first I thought this was just a slimy attack from one of those (clutching pearls as I say/type this) right-wing news organizations, but turns out its in the very trusted, totally-not-fake-news NYT. Seems Mr. Cuomo was asking for big donations from the state Hospital Association during his tough campaign last year. And once those payments came through, voila– higher Medicaid rates for hospitals! (and other providers, but in keeping with modern “journalism” I chose to emphasize the implication I wanted make vs the broader context).

CONGRATS TO OUR FRIENDS AT i2i- Big news late last week that i2i and Cerner are teaming up to integrate the power of their platforms. If you’re not familiar with i2i Population Health, they are now in 2,600 systems in 36 states providing various population health management solutions.

IDAHO JOINS THE GROWING RANKS OF WORK REQUIREMENTS STATES- The public comment period on Idaho’s work requirements plan (paired up with its Medicaid expansion rollout) is now open. Get ready to be called lots of names, Gem State friends.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award.  San Juan EMS will pay $350k for stealing from Puerto Medicaid with 400 medically unnecessary flights. Pamela Van Drie and hubby Lorin G. Van Drie of Springfield, MO will serve 5 to 10 years for stealing $885k. Their crimes? Providing dental patients with mouthpieces that cost $50, and then billing Medicaid $700 for “speech aid” prosthetics. The lovebirds also (successfully) billed Medicaid for dentures for patients who were not even on Medicaid (extra points!). Kathleen Service (actual last name- great name for a social worker if you ask me) of Hartford, CT stole $151k using other providers’ billing info. CT stopped allowing social workers to bill in 2017, but Ms. Service disagreed and decided to bill anyway (just with other people’s IDs who were still allowed to bill). Paul Peterson of Phoenix, AZ was indicted this week on charges of human trafficking and Medicaid fraud. His crime? He used his position as an elected official to traffic 28 pregnant women from the Marshall Islands to come to the US and sell their babies via an adoption scheme. The Medicaid connection- he also helped them get $814k in Medicaid benefits. Fly back east to Norfolk, VA to check in on Houman Motti. Mr. Motti will go to federal prison for using his ambulance company to steal $63k in Medicaid bucks. There is a lot of strong competition for this week’s award- what’s that? This just in from the judges booth: Mr. Peterson wins this week’s award! His total dollar impact was slightly less than the Van Drie’s, but he gets extra points for abusing his elected office to commit heinous crimes.

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (it finally rained here!) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: ‘ursil alab alaibn li’iinqadh alealam

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2o4qSFl

For optimist readers- http://bit.ly/35g3pBM  (read the comments on this one. Will make you smilecry)

AND SO IT BEGINS- Walmart opened its first “super center for healthcare services” in GA a few weeks back. Can you imagine what Medicaid spending will be like once Walmart is an enrolled provider? Will we be getting roll-back pricing on imaging, physician services and lancets? I sure hope so.

KEYSTONE STATE TRYING TO WORK OUT WORK REQUIREMENTS– Despite The Good Guvn’r Wolf’s veto-ing similar bills twice, reps in the PA state house are spinning up another work requirements bill. The main talking point that could get this one legs is from Sen. Martin of Lancaster County –  “This program, last year, grew by over one billion dollars. If it keeps growing at the pace it’s growing, the program is not going to be sustainable.” Mr. Martin, don’t you know Medicaid is different? Every time a Medicaid claim is paid, a Bitcoin is mined in the MMIS subsystem, thus creating new value. Medicaid is actually a money maker, sir. Get with it!

GA TRYING TO MAKE NEMT PERMANENT/ FOR REALS– While some states are relieved they don’t have to shell out millions for NEMT anymore (as CMS regs will likely make it optional soon), of course the low-informed press paints all this as “rolling back protections.” For those not familiar with NEMT, that’s non-emergency transportation- a benefit that costs $3B+/year. Its important, but also riddled with fraud and often crappy execution. Some states (particularly those with decent public transport) have already gotten approval to not have to pay for it. But I digress (into things like “details” and “balanced information”)- PeachState lawmakers are trying to get a bill that makes it state law to have to pay for it regardless of what the federalis do.

WE PROMISE THE NEXT $8B WILL TRANSFORM IT FOR REAL THIS TIME– NY’s first DSRIP waiver was focused on reducing hospital admissions by 25% (that did not happen). The next big idea being pitched to CMS (you have to have an idea that at least some sucker will buy; you can’t just come out and say the truth that you just need more and more and more Medicaid moula to keep the chaos going) is that the next $8B will move more payments into Value Based Contracts. Keep in mind the first version touted its aggressive move to value based contracts (something like 80% by 2020 I think). Value Based Contracts is now akin to “abracadabra”. Or, more accurately, “open sesame.” Waivers typically go about 5 years at a time (and are never not renewed), so my prediction is this one gets approved and in 2025 we will hear again that same abracadabra (value based contracting) and again open that sesame (another $8B+ spend).

AETNA SAYS NC SCORING SYSTEM UNFAIR- Aetna lost by a tiny percentage of points under the NC managed care RFP scoring system (there are many issues inherent with this procurement approach – hop on one of our monthly webinars to hear about them). But a new thread has emerged in which Aetna is complaining that one of the state scorers lives with a BCBS (a winner) employee. Best I can tell that’s the extent of their “unfairness” argument. And if NC is anything like AL (where I live), you can’t shake a dead cat (or stick or something. I can’t keep up with who is or isn’t offended by which version of that analogy; is that even an analogy? Is anyone really offended by it, anyway? Or do I just assume they are? Is that in itself offensive? Please members of the online outrage/cancel culture let me know in the comments) without hitting a BCBS employee. They are large employers in many states is what I’m saying.

CMS GETS NEW FRAUD TEETH- Its really hard to believe we will ever stop the flagrant fraud in Medicaid, but this is a new blip on the radar. CMS issued a final rule last week that lets them exclude providers in new ways and for longer periods of time. The gist is that docs with affiliations with parties with one or more disclosable events can now be nixed from the Medicaid funding gravy train (all these terms, with the exception of gravy, are defined in the reg here. For a solid gravy recipe, visit here). Under the new reg, docs can be banned from Caid for 10 years for the first offense (its now 3) and 20 years for the second offense.

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award.  Joseph Kimble of Longview, TX plead guilty earlier this month to using his company Tiger EMS to steal $750k (via bogus non-necessary ambulance rides). Skip on up to Union City, NJ and we find Alex Fleyshmakher, Reuben Sevumyants, Samual Khaimov and Yana Shtindler getting nabbed for stealing $99M from Care and Caid. What are they charged with? Using their pharmacies to get paid for scripts they never gave to patients and bribing doctors to help out with the scheme. Let’s head south to VA Beach, where we find Udaya Shetty pleading to stealing $460k for double, triple and quadruple booking patients and getting paid for it by Medicaid. Mr. Shetty (a therapist/psychiatrist) would spend about 5 minutes with patients, write a script and then herd the next one in. He then had his staff bill as if he had spent 40 minutes with each. While the total fraud on this one is $460k, Caid got taken for $161k, Care for $169k, TriCare for $72k and BCBS for $62k (kudos to the journalist for separating that out in the story). Keep heading south to Hotlanta, where Diandra Bankhead stole $1.2M of your tax dollars using a home health scheme involving medically fragile children. Her company “Elite Homecare” submitted 5,400 bogus claims to Medicaid. Head up to Balto (still below the Mason-Dixon line, though) to meet Celeste Bland-Guary. Celeste plead guilty to using her counseling business to steal $82K in Medicaid bucks. All things considered, the award this week goes to the Four Caballeros in Union City! We don’t yet know how much of the $99M they stole will turn out to be from Caid, but it will almost certainly end up being more than the other candidates!

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (it must surely one day rain, mustn’t it?) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: hav shlach levn latil at aavalm

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2MaW5ia

For optimist readers- http://bit.ly/2M8fsbh

IN CASE YOU HAVEN’T HEARD, THERE’S A DELAY IN NC- Well all you naysayers telling me you heard whispers of a delay back in August were right. It’s official, we have our first delay in the NC move to managed care. The Good Guvn’r Cooper is throwing a hissy-fit over this everyone-agrees-its-the-answer-to-all-our-problems-Medicaid-expansion thing, and he took his toys and went home when those “other” reps (voted in by some very deplorable people in a Russian-rigged election, I’m sure) were not so excited about a possible increase to the already murderous Medicaid cost trends [insert foolish, but confident economic theory here about “losing out on free federal money”]. Translation: Cooper fouled up the funding for managed care startup costs because he couldn’t get his way and score political points on Medicaid expansion. What was to be Phase 1 in November, will now be Phase 1 and 2 simultaneously in February. The Medicaid agency team is doing a great job of managing the chaos – but there’s only so much Cooper a successful transition can handle. He may end up being placated anyway- as of yesterday the house passed a gravy-train (Medicaid expansion) bill. That bill would expand under the pretense that work requirements and related premiums will be implemented. And we all know how that will turn out (just ask NH in case you have any questions).

MICHIGAN MCO MERGERS- Priority Health will gobble up Total Health Care. The gobbler has about $4B in revenue over 830k covered bennies; the gobble-ee has about $365M over 53k covered Medicaid members (96k total). To help grease the regulatory skids, Priority will be dropping $25M into a foundation to “fund a variety of non-profit initiatives” in Detroit.

FOSTER CARE IN ILLINOIS- IL DFCS is working to move 74,000 foster kids into managed care and some reps are raising concerns. The gist of the concerns are related to a rocky experience with MCOs in general. Here’s an idea you IL knuckleheads- actually pay the MCOs and it might turn out better (see previous reporting on how IL gets sued every 6 months or so and is forced to pay MCOs BILLIONS of dollars it reneged on). Here’s another idea- do a real audit of the quality of care for those foster kids now to see how well you are doing in the absence of managed care.

AL LAUNCHES ALABAMA COORDINATED HEALTH NETWORK (ACHN)- The state launches an expanded care coordination program October 1. About 750k bennies will begin to receive services designed to better manage their care. Childhood obesity, infant mortality rates and substance abuse are the top 3 targets of the new program.

AFTER THREE DECADES OF OPERATION, FEDS DECIDE TO TRY AND CONFIRM LIFELINE SUBSIDY ELIGIBILITY FOR REALS- If you are not familiar with Lifeline, it’s a $10/month subsidy for low income folks to get a cell phone. For 34 years you have been able to get one if you are eligible for Medicaid. Actually you have been able to get one if the phone carrier (who makes money if you are deemed eligible) says you are Medicaid-eligible. So now the feds decided to start verifying that with an independent system. An OIG audit found that 36% of bennies could not be verified as eligible back in 2017. Keep smiling while you pay for all this fraud, dear taxpayer.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award.  Felicia Blount of Gary, IN got 12 months in the slammer for stealing $195k Medicaid bucks. Her and her momma both falsified bills to Medicaid for transporting Medicaid patients to appointments. Dang, Felicia! Head on up (over?) to Columbus, OH where James McFadden was convicted of stealing $258,000 from Medicaid by faking PTSD and pretending he could not talk. His charade also required him to wear diapers. His co-conspirator got paid as his personal care aide to help with his bogus condition. Go west and we find 34 people in CA, AZ and OR nabbed in a $257M Medicare and Medicaid fraud scheme. The fraudsters used various means involving medically unnecessary tests and prescriptions.  And finally (there are at least a dozen more on my desk I could write about this week, I just need to land this plane)- let’s fly back to the heartland to check in on Craig Barnett of Nebraska. Barnett is a former Medicaid auditor now serving jail time for stealing $277k using his father’s power of attorney. He used that power to take SSI monies, raid mutual funds and falsely obtain nursing home coverage (which is where the Medicaid part comes in) for his father. He was head of the NE Medicaid Audit and Financial Support Division the whole time. Mr. Barnett, I hope you can come to some sense of right and wrong as you stare at those prison bars. But in the meantime, you win this week’s award!

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (assuming you don’t find yourself suddenly living in a parched desert like I do) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: батько послав сина, щоб врятувати світ

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2Y8ReSk

For optimist readers- http://bit.ly/2Y93BOl

AND SO IT BEGINS (MCO ENROLLMENT IN NC)- Open enrollment for the first ever Medicaid managed care plans in the Tarheel State began this week. 540,000 members in 27 counties can pick their insurance cards until September (if they don’t pick, one will be picked for them). There could be a monkey wrench though- the MCO rollout costs about $200M in start-up money. And that money is tied up in fights over the current state budget. The Good Guvn’r Cooper is trying to use this fight to force expansion on the state and vetoed the latest Republican compromise bill. Stay tuned.

IOWA RATES FINALLY FINALIZED 2 WEEKS INTO FISCAL YEAR– Which is better than last year which went 2 months past the contract start dates. MCO rates got bumped another 8.6%- but that’s all going right back out to providers (facilities, mostly) and Big Pharma (hep c coverage). There is also new funding included for more MCO “oversight.”

FL COUNTIES RAISING ALARM OVER TRUE COSTS OF MEDICAID EXPANSION DREAMS– See, all that “free” Medicaid money comes from somewhere, even at the state level. And in many states, a ton of that state money comes from counties, who must fund it with property taxes. So, one neighbor’s millage is another’s Medicaid. Whether the funding neighbor likes it or not (or even knows it). Well in FL (where they Expansion Lobby incessantly tells everyone they must expand, just like in every other non-expansion state), some small counties are trying to build awareness. It doesn’t hurt that Florida has a law that requires actual economists (which are different from NYT columnists promoting junk science, by the way) to assess the financial impact to Florida’s “fiscally restrained” counties.

MANY STATES TALK ABOUT CONTROLLING OUT OF CONTROL MEDICAID SPENDING DEATH SPIRAL; ALASKA IS ACTUALLY DOING IT- AK Governor Dunleavy is not playing the normal game of “appear hard on Medicaid spending but eventually cave” and just do what the Medicaid lifers (and industry lobbyists) tell you to do. The Good Guvn’r just vetoed $58M in state monies for Medicaid (including jettisoning the adult preventive dental benefit). The immediate, across-the-board provider rate cuts triggered a lawsuit from the Alaska Hospital and Nursing Home Association (the groups who get the lion’s share of the Medicaid biscuit). Yeah, I just replaced pie with biscuit- and you love it. Hold on tight, Guvn’r.

ID SUBMITTED A 1332 WAIVER TO ALLOW MEDICAID EXPANSION MEMBERS TO NOT ACTUALLY HAVE TO BE ON MEDICAID- Idaho is expanding Jan 1, 2020. Right now there are about 18,000 Idahoans on the exchange who will have to drop their commercial policies because they would qualify for Medicaid. The state has asked CMS for permission to instead subsidize their exchange premiums instead of moving them onto Medicaid. Analysts currently expect CMS approval, since it is similar to a request approved for Utah earlier this year.

 

I SEE WHAT YOU DID THERE (EMPIRE STATE SHENANIGANS MEANT TO COVER UP FAILURE TO CONTROL MEDICAID OVERSPENDING)- This one is delicious. The good Guvn’r Cuomo quietly slid $1.7B in Medicaid spending by delaying a payment 3 days. Why does that matter? Because it was at the very end of a fiscal year, and it allowed the state to look like it was compliant with state law that keeps Medicaid spending increases capped at 3%. If the transaction were made when it was supposed to (and more reflective of actual costs and spending, which is of course more in keeping with both the letter and spirit of the law), then the state’s fiscal failure would be obvious. Its looking like the state is on track to overspend again this fiscal year. Don’t worry, they will just slide the payment again next year!

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker- no fraud follies this week, friends. Just not enough time in the day or space in the column. Let’s all just pretend its not happening this week (makes me feel better, anyway).

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (pressure wash your driveway, its miraculous!) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: Äkesi Ulın qutqarw üşin jiberdi

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2XR8wTL

For optimist readers- http://bit.ly/2XQzwD0

CA MAKING IT EASIER TO TEXT- While it pains me to realize that 1991 is now 28 years ago (1991 is when the law blocking spam texts was passed; its also when this album came out and changed all of music), it does seem like maybe our SMS policy needs a touch up. See, when healthcare companies can’t use the communication method that 50% of Americans say is their primary day to day method, we have a problem. Why can’t an MCO text Clay the Medicaid bennie? Because laws. And stuff. The California health agency is working to remedy that by laying out some basic ground rules to make it easier for MCOs. Summary of the rules: submit a form to the state to text to members, make it free, give them an opt-out option and let us know your game plan re: privacy protections (hint- don’t let Amazon or Facebook access the info so they can market them new products via their discounted Medicaid/EBT Prime accounts).

GARDEN STATE WELCOMES NEW DIRECTOR TO THE HELM- Jennifer Jacobs will be the next New Jersey Medicaid Director by late July. Jennifer- We’re glad you’re here!

INDIANA WORK REQUIREMENT BEGAN LAST MONDAY- By Tuesday morning, there were 17 lawsuits filed, 4 HuffPo articles explaining how Evil this is, 2 protests in the streets and 4 new Democratic Presidential Candidates. Ok that last one was unrelated to the work requirements program beginning. Members subject to the requirements (as in all the of the states trying to roll out this feature, almost all members are exempt) will have to work 20 hours a month in year 1 (which boils down to 5 hours a week, or 1 hour a day, M-F).  So 240 hours of total work to obtain a benefit valued around $6,000 comes out to being paid $25/hour if you have to work for your health insurance.

OREGON MCO AWARDS ARE OUT- CCO 2.0 (Coordinated Care Organizations, for those that missed the first memo 5 years ago about how this was the next great idea that was going to save Medicaid from a financial death-spiral) is now live after the MCO awards were announced this week. All incumbents won except for 1 (Primary Health), with 4 newbies given 1-year contracts as a type of probation.  Congrats to our friends and clients in the winning orgs. Here’s to five more years!

EMPIRE STATE TAKING LTC RESIDENTS BACK OUT OF MANAGED CARE- Under new NY policy, skilled nursing facility residents will be back in fee for service if they are in a facility more than 90 days (assuming the carve-out is approved with the CMS waiver in play). The thinking behind the change is that there’s not a lot of cost management achievable for long term institutional residents (NY thinks they will save $158M savings in the first fiscal year)- so why pay an MCO basically an additional administrative fee. I personally am skeptical that there is no room for efficiencies in nursing facility management, but we shall see.

NEED A JOB IN ILLINOIS? There are 300 new job openings to help deal with the pile of Medicaid applications that are backlogged (more than 100,000 currently, which are older than 45 days – which is non-compliant with federal rules).

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award. Not a lot to cover this week, but let’s at least scratch the itch… Vasso Godiali of Bay City, MI got popped for his role in a $60M healthcare fraud (not sure how much was Care vs Caid). Seems he had a penchant (been a while since I used that word) for bogus stent claims. What started out as a Medicaid fraud case got bumped up to include Medicare when the state folks realized they were just the tip of the iceberg. Qaiser Gondal of Watervliet, NY plead out in Albany this week. He was part of the dozen or so thugs using Ti Taxi to steal multiple Medicaid millions. And finally, Nikkitta Chesney of Bridgeport, CT joined her partner in crime (Toshirea Jackson) at the sentencing hearing for their Medicaid fraud. Their crime? They stole Medicaid bennie IDs (about 150 of them) and then used them to steal $3.9M using fake claims for psychotherapy services. The lovely ladies Nikkitta and Toshirea are our winners this week, albeit on a technicality (since we don’t know the Care/Caid loot mix for Mr. Godiali). Congrats, fraudsters! You get a Mostly Medicaid Fraud All-Stars T-Shirt. It comes in orange and also in orange.

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (if you bag the grass when you cut it, it does really help with weeds after a few years. Every think about how many seeds are in the soil in your yard? Scientific notation is surely required) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: Chuir an t-Athair am Mac gus an saoghal a shàbhaladh

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2JjSCxc

For optimist readers- http://bit.ly/2JjuTNU

HAPPY BIRTHDAY TO YOU- Happy birthday to you. Happy birthday, dear America- Happy birthday to you!

RATES? WE DON’T NEED NO STINKIN’ RATES- On July 1, MCOs in Iowa began another fiscal year without official capitation rates (the same thing happened last year- it was 2 months before rates got locked down then). Last time this happened it didn’t turn out too bad for MCOs, though: They got an 8.4% bump.

CMS FUNDING NEW OPIOID TREATMENT GRANTS- CMS announced new $50M grants available for states to improve substance abuse treatment and recovery efforts. The feds are looking for proposals that would fund 18-month pilots. Applications due August 9^th.

PRAIRIE STATE OWES FEDS LOTS OF DOUGH- Seems Iowa did not collect rebates on about $7M worth of Medicaid drugs. Federal HHS IG sent a letter looking to collect on the $4M federal share of those rebates. HHS has been reviewing state rebate collections, with Illinois being the 36^th state to have its tires kicked. NJ has been asked to pay back $8M.

SOONER STATE DOES, TOO- Oklahoma had some recent success suing Purdue Pharma. By success, I mean they got a settlement of $270M awarded (all related to Purdue’s OxyContin marketing practices, I think). Well someone at CMS saw the news and sent a letter to OK Medicaid making sure they knew the feds were entitled to some of that money. The Good Guvnr Stitt is currently saying no dice, federalis.

NH TWEAKING WORK REQUIREMENTS- Dem state reps have been trying to undo the deal they made to keep expansion going. Looks like a compromise is being struck- the requirements stay, but there are now no penalties for non-compliance.

AK TIGHTENING THE BELT- The Good Guvnr Dunleavy is cutting $444M from the overall state budget, with $50M of it coming from Medicaid. Here is a quote that will strike terror in the heart of Medicaid-industry lifers: “Cost-saving measures can be achieved in the Medicaid program through creativity, program reform, and focusing on fraud.” What the heck does he mean cost savings through creativity? Reform? Focusing on fraud? How dare he?! Has no one told him yet the way Medicaid actually works? Someone talk to this man!

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award. Brenda Copeland of Warner Robbins, GA stole near bouts $500k using her counseling business. She was charged this week with filing false claims (and I think it may have been to an MCO, but not sure. If you are, please weigh in). Move on up and over to Pulaski County, Arkansas where we meet Charline Brandon. She has to pay back $289k to AR Medicaid for tricking patients into thinking they were dying so they would sign up for hospice (that’s a particularly special kind of cruel). One victim spent 3 years in hospice. For another entry in the despicable department, head back east to Greensboro, NC. Here we meet the good people at United Care Youth Services. According to allegations made by patients, this outfit is requiring people to stay hooked on drugs so they can stay in their housing program. Plaintiffs say they were provided free or reduced housing as long as they did not have 3 clean, consecutive drug tests. The organization also provided classes and substance abuse treatment, then billed it to Medicaid. As of the time of writing all allegations were being denied but state investigators are looking into this and other similar schemes. Ann Eldridge and Angela Keith of Sumter, SC are wrapping up their court adventure over their pilfering of $13M from Medicaid. How did they do it, you ask? Using their organization (Early Autism Project) to bill false claims over a 9-year period. The two ladies ended up getting 6 months in prison… Ok enough southern-fried fraud- lets move this party up North. Crispin Abarientos of Middletown, CT plead guilty to getting $894k worth of Remicade (an injectable used for rheumatoid arthritis) using false claims to Medicaid. He then turned around and used that Remicade on commercial or Medicare members and got paid by those payers. So get some “free” Remicade (paid for by Medicaid-funding citizens), then sell it to Medicare and commercial plans. Total taxpayer tab (grin and bear it, you suckers!) for this paragraph: $14.7M. Our illustrious ladies from South Carolina (Mrs Eldridge and Mrs Keith), you win this week’s award.

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (stare long and hard at those almost-ready tomatoes) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: Chúa Cha đã sai Con đến cứu thế gian.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2VPQsbU

For optimist readers- http://bit.ly/2VPQuk2

 

KNOW WHY YOU GET TO GRILL BURGERS ON MONDAY? Because brave soldiers died protecting you from threats home and abroad. Take a moment to learn about a few heroes who died recently- http://apps.washingtonpost.com/national/fallen/

 

OKIES DARING TO FOLLOW REGULATIONS AND CHECK ELIGIBILITY BY MAIL- In order to make sure the member rolls are accurate (sort of an important thing, especially in managed care states), CMS requires states to, you know, verify members exist. Part of that involves attempting to contact them. Attempting to contact them by mail is how CMS suggests to do it. Oh yeah- it also proves you live in the state (a term called “residency”). In the never-ending story of making it impossible to actually be a good steward with hundreds of billions of dollars, #Resisters in OK are ticked about a proposed rule to take bennies off rolls if the letters they send are returned undeliverable. Next year all it will take to get a Medicaid card will be to wish upon a unicorn’s left hoof and “poof” – you’re in!

CMS JOINS SPREAD PRICING FRACAS- Last week the Big House released guidance to states and plans about how to view spread pricing and MLR. The gist – it does impact MLR and any vig that an MCO paid to a PBM via spread pricing does NOT get to count as medical costs. Go figure.

LEARNING MORE ABOUT NC SDOH PILOTS- Key things you need to know: $650M will go to pilot programs for 50,000 bennies ($13k/each for Roundup Readers playing at home). Programs will address housing, transportation, food, and interpersonal violence. MCOs will manage the budgets for each benny in the pilots. RFPs for the Lead Pilot Entities (LPEs- the network builders) expected round about Thanksgiving.

BYE, MR. TRAYLOR- Chris Traylor, current head of the CMS Medicaid and CHIP services unit, will be stepping down on May 31. Calder Lynch (who did our state spotlight show a few years back) will be acting director.

 

BUT, YOU SEE, IT DOES FURTHER THE GOALS OF THE PROGRAM- When we’re not blowing money on people who don’t care enough to comply with paperwork, there’s more money to help the sick people on Medicaid waiting lists. At least that’s the argument being made in the Trump Team’s appeal of the work requirements lawsuits. Keep in mind the argument in the suit that slowed work requirements was that they did not further the goals of the Medicaid program. By showing how the new requirements do further the goals for the people who need it most, Team CMS has accomplished what in policy debate is known as a “Turn.”  Or maybe they’re obstructing some sort of Russian dossier under the emoluments clause of the 32^nd amendment or something. Who knows? Rachel Maddow, that’s who.

 

ANOTHER OH MCO DROPS CVS- Buckeye Health dropped the drug giant this week. Caresource led the way a few weeks back.

============================================

BEGIN SHAMELESS PLUG SECTION

=============================================

THE MEDICAID BLACK BOOK IS HERE- Want to know what’s on the mind of MCO CEOs? Want to see our in-depth reviews of vendors? Current issue is out. You can check it out here – http://www.mostlymedicaid.com/?product=medicaidblackbook

Companies reviewed in current issue:

1. Apixio
2. CareCentrix
3. Digital Harbor
4. HealthCrowd
5. InComm
6. Lucina Health
7. Medical Advantage Group
8. Moms Meals
9. NowPow

• Vheda Health

======================================

END SHAMELESS PLUG SECTION, RETURN TO AMAZING FREE INSIGHTS

======================================

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award. Sort of a slow fraud week, so your chances of winning are higher. Hellen Kiago, of Sturbridge, MAH was convicted of stealing $2.5M from MA Medicaid. Her crime? She used her home health agency to bill for unnecessary services and falsified documents. Fun fact- once the coppers searched her office, she wired $1.5M to Kenya. Alejandro and Alexander Jiminez-Incera of Las Vegas were sentenced for stealing $3.7M from Care and Caid. They got caught because of a cash-for-opioids operation they were running, then investigators caught onto a bigger fraud where they were billing for patients they never saw.  Margaret Williams of Anchorage, AK was sentenced this week. In addition to getting one of her nursing home staff killed by having them work entirely alone amongst 5 residents with violent records, and not reporting the death within 8 hours, Maggie stole $1M from Medicaid by billing for services not provided. The Lifetime Movie is due out next week. Mrs Kiago – you win this week’s award for quick thinking in times of pressure. Taxpayers – shut up and smile while you watch your money go down the drain.

Need even more Medicaid fraud stories? – You can get your fix in the FWA Curator archives.

Want to read the articles summarized here, highlighted for your reading pleasure? Check out the News Curator archives.

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (water and weed, water and weed) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: Chúa Cha đã sai Chúa Con đến cứu thế gian.