Tag: Providers

MM Curator summary

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

 
 

[MM Curator Summary]: The largest FQHC in the nation has been found to be participating in massive, egregious fraud.

 
 

 
 

Clipped from: https://www.dentistrytoday.com/fqhc-borrego-health-files-for-chapter-11-bankruptcy-protection-an-analysis/

 
 

 
 

Borrego Community Health Foundation (Borrego Health) filed for chapter 11 bankruptcy protection on September 12, 2022, in the US Southern District of California (case no. 22-02384). Borrego Health claims assets of approximately $50-100 million, and liabilities of approximately $50-100 million. Formerly, Borrego Health was asserted to be the largest federally qualified health care (FQHC) non-profit organization operating in the nation.

 
 

PENpics Studio/shutterstock.com

Most of its production income allegedly originated from various schemes of abuses and fraud related to dental encounter fee agreements, by subcontracted private dentists.

Unlike typical subcontracted dental care from FQHCs, these uniquely constructed agreements by Borrego Health paid private dental providers on an encounter fee basis, and not via a fee-for-service methodology. As such, without intensive oversight by Borrego Health’s chief dental officer, Dr. Timothy S. Martinez, and his subordinate staff, fraud and abuses were seemingly encouraged. The FBI raided Borrego Health and its retained billing contractor, Premier Healthcare Management, on October 20, 2020.

One of the alleged more egregious contracted dental providers was Dr. Husam Aldairi and 40/30 Dental, which the new administration of Borrego Health has sued in a civil legal action and disputed him as a creditor. His extensive disciplinary actions from regulatory boards and failures to comply with consent agreements before the Illinois Dental Board and Illinois Department of Financial and Professional Regulation were public record, prior, and during his contracted time with Borrego Health. Also problematic were disturbing misrepresentations by Aldairi and a discipline ruling, and judicial fine handed down against Aldairi, in his Illinois bankruptcy.

All this troubling public record data related to Aldairi was easily accessible to the Dental Board of California (DBC), which credentials and renews dental licenses. It was also available to the California Department of Health Care Services (DHCS) which approves and renews credentialing for Medicaid providers. It was also easily obtainable through a due diligence vetting process under Borrego Health’s former chief dental officer, Martinez.

In fact, Martinez, under oath and under questioning by his attorney, stated, “I have done clinical work, but also part of my specialty is Medicaid fraud. So, I’ve worked with dental investigations both – all over the United States… Basically my background is in Medicaid fraud.” (Superior Court of the State of California, in the County of San Diego, Sept 7, 2022, case no. 37-2021-00049304, in the matter of Martinez and Tuso).

Few would dispute Martinez’ knowledge and expertise in the field of dental Medicaid fraud.

Aldairi has never been disciplined by California regulators related to Borrego Health, or Illinois consent orders and failure to comply with consent orders in Illinois (which concurrently represent violations in California). Although he was disciplined for an unrelated violation by the DBC, Aldairi maintains Medi-Cal credentialing and a California dental license.

Eye-Rolling Bankruptcy Creditors

Daniel Kramer, chief of media and public relations for Borrego Health, stated for Dentistry Today, “Parties included on the list of noticed parties are not all creditors and do not necessarily have claims against the debtor (Borrego Health). The list represents parties who may have been vendors to Borrego Health in recent years. The list also includes current and former employees who may have incurred expenses on Borrego Health’s behalf using a personal account in recent years.”

The listing of creditors is beyond astounding and points to scandal on a massive scale. The number of high-profile Las Vegas casinos and resorts is disturbing, especially for a nonprofit IRS 501c company.

These include:

• Caesar’s Palace
  
• Mandalay Bay Resort & Casino
  
• MGM Grand Hotel & Casino
  
• Mirage Hotel & Casino
  
• Paris Hotel & Casino
  
• Planet Hollywood Resort
  

Locally, the Spotlight 29 Casino in Coachella, California, earned an entry on the creditors’ bankruptcy role. Not making this record was another neighboring gambling casino, Sycuan Casino. However, this casino was mentioned in formal discipline considerations of the DBC against Aldairi, in a matter totally unrelated to Borrego Health.

“Complainant alleges that on or about September 10, 2019, the Sycuan Tribal Police arrested Respondent (Aldairi) at the Sycuan Casino for being drunk and disorderly in public. He was loud and disruptive, and refused to leave the casino voluntarily even after police arrived. He asked the police to arrest him.”

Other questions can be raised by the extensive number of party supply companies, flower shops, and event planning firms which made the creditors’ register. Additionally, a musical instrument sales outfit (Guitar Center) was included. Rarely does one consider a FQHC nonprofit healthcare provider as “party central.”

The creditors also included an extensive number of auto dealers, car detailing companies, as well as auto repair and towing enterprises. One would reasonably expect auto leasing, purchasing, and maintenance for vehicles utilized by home health nurses, and social services for homebound patients. It might include transportation services for non-ambulatory patients to and from Borrego Health clinics. Kramer stated, “Borrego Health owns and leases vehicles for a variety of care-delivery and business purposes.”

This vast listing related to autos should not include private transportation vehicles for senior Borrego Health officers and directors, especially of a nonprofit entity. A forensic accounting would be reasonably essential for determination, based on the troubling history of Borrego Health.

Party Central at Borrego Health

Luxury hotels and resorts locally, nationally, and internationally were also named. Moreover, limousine services and airlines also were included.

Some are cited as follows:

• Alaska Airlines
  
• American Coach Limousine (Chicago)
  
• Caribe Royal Resort (Orlando, Florida near Disney World)
  
• The Colony Palms Hotel and Bungalows (Palm Springs, California)
  
• Diamond Limousine (Hughesville, Maryland)
  
• Gaylord Hotel Opryland Resort (Nashville, Tennessee)
  
• Hyatt Regency Huntington Beach Resort
  
• Hyde Resorts (Hollywood, Florida)
  
• InterContinental Hotel (luxury hotel near French Quarter in New Orleans, Louisiana)
  
• Jake’s (fine dining in Palm Springs, California)
  
• Julian Gold Rush Hotel (Julian, California)
  
• La Casa Del Zorro Desert Resort and Spa (Borrego Springs, California)
  
• Mears Transportation (limo transportation in Orlando, Florida)
  
• Miracle Springs Resort & Spa (Hot Springs, California)
  
• Palm Springs Riviera Resort & Spa (a/k/a Margaritaville Resort)
  
• The Royal Crescent Hotel & Spa (Bath, United Kingdom)
  
• Sonesta Hotel (Philadelphia, Pennsylvania)
  
• Southwest Airlines
  
• The Mission Inn Hotel and Spa (Riverside, California)
  
• United Airlines
  
• The Watergate Hotel (Washington DC)
  
• The Willard InterContinental Hotel (luxury historical hotel near White House in Washington, DC)
  
• Walt Disney Resort (Orlando, Florida)
  
• Westgate Lakes Resort and Spa (near Walt Disney World and Sea World Orlando)
  

An unusual number of creditors were recreational vehicle (RV) sales and service companies. A specialty custom trailer hitch supplier was included as well.

Borrego Health does support a number of mobile medical and dental clinic vehicles, which may explain some of this expensing. Kramer advised that Borrego Health operates ten mobile health units. Again, a forensic accounting would be necessitated to ensure Borrego Health resources were not diverted.

Construction & Land Development

Apparently out-of-place were various firms focused within the construction and land development industry. These included a roofing company, an asphalt supplier, multiple plumbing and backflow companies, a variety of industrial crane operators, lumber supply, and a host of landscaping and pool companies.

Further forensic investigation might confirm or deny, whether all or some of these construction and landscaping operations were solely for structures owned and operated by Borrego Health. Kramer stated, “Borrego Health operates multiple facilities throughout its service area.”

A nonprofit healthcare corporation should never be subsidizing expenses which should rightfully be borne by others, particularly in construction and land development. A FQHC should not be paying over-inflated rental fees, especially on properties which they developed and maintain. Borrego Health should not be subsidizing the construction costs of unrelated projects. Such an unlawful activity might be viewed as a form of money laundering and fraud, perpetrated by those benefiting.

Dental

The creditors’ list also cited over 20 outsourced dentist contractors and clinics. These private sector dentists and their clinics were sometimes listed as “disputed,” which implied allegations of Medicaid abuses and fraud, and/or a failure to meet terms of Borrego Health provider contracts. Two of the disputed entities are the aforementioned Aldairi and 40/30 Dental.

Another listed dentist creditor holds a public record disciplinary action from the Alaska Board of Dental Examiners, which resulted in profound injury to a patient. This did not elicit the BDC to sanction his dental license. He continues to maintain Medi-Cal credentialing under the California DHCS. Obviously, any due diligence by Martinez and his crew acting at the behest of Borrego Health did not exclude him as a contracted provider.

His dental group practice (small dental service organization – DSO) includes other troubling practitioners with a CDB history of “Malpractice Judgement.” One is left to speculate on the judgement of Martinez and Borrego Health to contract with a questionable DSO and their doctors, without intensive on-site clinical record inspection and monitoring of patient care, even assuming Borrego Health decided to contract with such dubious dental providers.

A different contracted dentist serving patients of Borrego Health had prior DBC public record disciplines related to:

• “Epinephrine induced temporary myocardial (stunning), but her heart suffered no permanent heart damage.”
  
• “Respondent (dentist) recorded no periodontal charting on Patient’s teeth. Based on his examination and x-rays, Respondent recommended cleaning Patient K.T.’s teeth, placing fillings in two teeth (teeth nos. 2 and 15), and a periodontal program, including deep cleaning. Patient K.T.’s parents sought a second opinion from Drs. R and S. Both doctors agreed that a periodontal program, including a deep cleaning was not necessary. Additionally, Dr. S determined that tooth no. 2 did not have a cavity or require a filling.”
  

Although this dentist’s license was revoked and subsequently immediately reinstated by the DBC, one might assume his Medicaid credentialing by DHCS would receive close monitoring, if not suspension or revocation. Similarly, one might question the wisdom of Borrego Health entering into Medicaid patient care contracts with this provider, without extremely close observation, if at all, for such a vulnerable Medicaid patient population.

The Borrego Sun reported on an extensive list of civil and criminal allegations against Borrego Health’s contracted dentists. These doctors and one dental assistant (allegedly providing unlicensed dental services) were named on the Borrego Health bankruptcy creditor list.

Two dentists, who were supervised by Borrego Health dental director Martinez, also made the extensive bankruptcy creditor tally. These were Martinez’ immediate subordinate, Nithya Venugopal, DMD, and his hand-selected investigator Elias Koutros, DDS, from Rhode Island.

Venugopal, formerly assisted directly under Martinez, is today serving with Borrego Health’s new Compliance Committee after the company shakeup. According to the Borrego Health website, “Under her leadership, she will oversee her team in the review of Medicaid provider activities, audit claims, and educate providers and others on the Denti-Cal program as it pertains to FQHC’s in our state.”

As reported by the Borrego Sun, “She failed in that role, for whatever reason. While like many others who remained silent about what they had to know was illegal, including former members of the Executive Committee of the Borrego Health Board of Trustees, it isn’t fair to place responsibility on her, but so many people, like her, had a choice to do something or go along. And unfortunately, they made the decision to go along, either for job security, friendships, or because for so long there were no repercussions.”

“One culprit of questionable character, Dr. Elias Koutros, is no longer being paid for medical (dental investigative) services. The doctor holds licenses in Rhode Island, and two other states (California dental license issued September 2019), and allegedly audited the Borrego Health dental clinics, even though a medical (dental) doctor, living on the East Coast. Go figure that one out? He was later hired at Borrego Health and listed in the foundation’s IRS reports as one of the highest earning personnel that was not an officer. Evidently, he had friends in high places.”

Martinez reached the creditor sheet as well, along with Maura Tuso, DMD, MS. Both are currently embroiled as adversaries in the previously cited civil legal case. The action involves a suit and countersuit for alleged harassment and restraining orders.

Martinez also serves on the Dental Hygiene Board of California (DHBC) and was formerly president of that state regulatory board. He regularly confers and collaborates with its sister state regulatory agency, the DBC. In this capacity, Martinez has routine ongoing contacts with board members and board directors appointed by Governor Gavin Newsom, as well as board attorneys assigned by the California Attorney General’s Office.

Nikki Symington of the Borrego Sun reported on November 11, 2021, “How did Dr. Timothy Martinez, Borrego Health’s Chief Dental Officer, liaison between Premier Healthcare Management and Borrego Health, not know there was cheating going on right under his nose? An intelligent man with a solid resume, Dr. Martinez probably helped Bruce Hebets (former Borrego Health CEO) develop the idea (this unique form) of contract dentistry and the management structure. Martinez has a professional history of advocacy for contract dentistry as a way for dentists to benefit and reach more of the underserved.”

“Actually, the one thing Martinez can’t say is that he didn’t know about Aldairi’s illegal activities. Dr. Maura Tuso, a dental endodontist, went to great lengths to alert him and others that Dr. Aldairi was breaking the law.”

Daryl Priest and Companies

Noted Riverside and San Diego Counties real estate and land developer, Daryl Priest, some of his companies and his son, Nicholas Priest, were also named on the bankruptcy creditors’ filing. Allegations in a lawsuit of Borrego Health against Daryl Priest’s dental Medicaid billing firm, Premier Healthcare Management (Nicholas Priest was former Executive Director) contend the company grossly overcharged Borrego Health for outsourced billing services. Allegedly, Priest’s Summit Healthcare Management, Inc. was a mirror image with medical Medicaid billing services. The Borrego Sun produced a good summary of that lawsuit.

Each claim processed was allegedly charged up to $25/ per billing form submitted. Plaintiffs contend this represented a method of money laundering, to enrich those controlling the lucrative business of Medicaid fraud by a FQHC. Make no mistake, Medicaid fraud is by far, the most lucrative business model in the dental industry.

All the while, corporate officers and directors at Borrego Health initially reported no malfeasance, for a prolonged period of years. Eventually, after federal and state investigations, a massive shakeup in corporate control of Borrego Health occurred. If and when insider whistleblowers initially stepped forward, at personal risk to themselves and their careers, they were ignored, discredited, and silenced.

Investigative reporter for the Borrego Sun Nikki Symington stated, “Simply leasing out the non-profit status for a fee and the ability to access federal and state funding allows Borrego Health to not just grow, but increase revenues exponentially. All without the headaches of actually delivering health or dental services.”

“Bruce Hebets (Borrego Health’s founding CEO) originally put forward the concept of getting out of providing services by simply facilitating private providers to benefit from Borrego Health Foundation’s non-profit status for a fee. Using Premier (Healthcare Management) as the middleman manager of the private providers, the (Borrego Health) Foundation has expanded this program beyond Medicaid dental services to actual Medicare health services. Anderson (Borrego Health board member and former chairperson) admitted, at least three clinics are not being operated by Borrego Health, but by private providers, under contract with Premier.”

“The reason is: It costs to provide services, and management of clinics requires expertise and work.”

Rents paid by Borrego Health for real estate holdings of Daryl Priest and his companies are also the focus of current litigation. Plaintiffs contend property rental fees were intentionally overinflated, to launder money to Priest holdings as alleged in a civil RICO lawsuit.

Investigative reporter Symington offered, “Can the (Borrego Health) Foundation recover the millions of dollars Hebets and his successor, former CEO Mikia Wallis, gave to the likes of Daryl Priest? And, not just for the $11.5 million in inflated rent fees, the subject of Borrego Health’s current legal suit. But the estimated $100 million sucked from the Borrego Health budget and the clinics by Priest’s privately-owned company – Premier Healthcare Management.” (Note: Many consider those exceptionally low dollar estimates of the actual alleged fraud.)

Management

Borrego Health’s founding CEO was retired Port of San Diego Police sergeant, Bruce Hebets, who died in 2019. That year he was paid the salary of $1.9 million. The year after his death in 2020, Hebets was paid over half a million dollars. He held no prior background or experience in healthcare or corporate financial administration. He was purported to have been a close personal friend of local real estate entrepreneur and philanthropist, Daryl Priest.

The late Bruce Hebets was not cited on the bankruptcy creditor list, but his wife and heir Karen Hebets was named twice. She was not only heir to her late husband’s (Bruce Hebets’) estate, but also served in administration of Borrego Health. Obviously, ethical considerations of nepotism were not a factor worthy of review.

According to the Borrego Sun, “She was given $3 million ‘to support and sponsor,’ and loaned another $460,000 plus, by Borrego Health to a private healthcare network the Hebets’ founded called, Borrego Independent Physicians Association (BIPA). The BIPA advertised dental, pharmaceutical and OBGYN services in San Diego Directories.”

Borrego Health submitted on its 2019 IRS form 990 form, that dental encounter fees accounted for 63-65% of its income, which included nearly 900,000 patient visits.

Consulting and Insurance Contractors

The standouts on the bankruptcy listing included James Hebets, brother to the late Bruce Hebets, The Hebets Company, and NFP Insurance Services.

James “Jim” Hebets is the founder and president of the Hebets Company, which is today in the portfolio of NFP.

Their website espouses, “The firm specializes in the areas of executive compensation and fringe benefit consulting, business succession planning concepts, wealth creation and estate preservation strategies and the facilitation of the purchase of extremely large amounts of life insurance.”

The Hebets Company openly promotes “estate planning for the exceptionally wealthy” and “… facilitating a strategic national approach to Federally Qualified Health Centers. The Hebets Company has over 45 years of experience in delivering some of the highest quality compensation and benefits consulting and service to healthcare executives and providers around the country.”

“The Hebets Company’s Executive Compensation and Supplemental Fringe Benefits division assists these enterprises in designing and implementing innovative compensation and benefit programs for purposes of recruiting and rewarding those key executives who are instrumental to the profitability of the company. Legislative changes over the years have repeatedly reduced the qualified plan benefits that can be allocated to this select group of highly compensated employees resulting in ‘reverse discrimination.'”

A primary focus of the Hebets Company is to maximize compensation packages for officers and directors of nonprofit FCHCs.

“We will evaluate the current FQHC compensation and retirement models, educate the FQHC executive team along with the Board of Directors regarding the compensation opportunities specific to not-for-profit organizations, and make a suggestion for the most appropriate model applicable to the specific FQHC. These options include a wide variety of governmentally sanctioned programs that have been codified in the Internal Revenue Code under the following sections: 162(b), 457(b), 457(f), 403(b), split dollar plans, executive/employee bonus programs, and other bonus retirement hybrid strategies. Additionally, there are other insurance and benefits based programs available to employees of not-for-profit FQHCs that may warrant exploration.”

In essence, compensation, and benefits for senior personnel of FQHCs are not reported as salary on IRS form 990, Schedule J, but shift to less transparent mechanisms. Only a deep forensic accounting could determine the degree to which Borrego’s officers and directors were truly remunerated.

Word has definitely gotten out about the lucrative positions of senior management generated within nonprofit FQHCs and how The Hebets Company can facilitate wealth creation.

“Today, we’re fortunate to serve more than thirty FQHCs across the country, including several of the ten largest.”

The Hebets Company is deep into reversing “reverse discrimination” foisted upon the super-wealthy.

What happened at Borrego Health may only be a tiny segment of a much larger pattern of deception and abuses, on a national level within the corporate nonprofit FQHC industry.

CONCLUSION

The size and scope of happenings at Borrego Health impact every taxpayer, not only in California, but in the country. Medicaid is jointly funded through state and federal moneys. The US government might be entitled to recover mismanaged Medicaid funds via claw-backs, from the State of California. Forensic accountants from the IRS and FBI should place this case front-and-center. The California Department of Insurance should analyze exactly how officers and directors of Borrego Health may have received “hidden” compensation.

State regulators inclusive of the DBC and California’s DHCS were either asleep-at-the wheel, or more likely tacitly complicit. The US Health and Human Services Office of Inspector General has repeatedly repudiated “Pay-&-Chase” has a highly ineffective means for recovery of taxpayer money. State authorities appointed by the California Governor and Attorneys General Office arguably facilitated a coverup. Dentist wrongdoers were either ignored or sanctioned for unrelated actions. Martinez, to this day, serves on a dental state regulatory agency.

Priest is a board member in the Lincoln Club of San Diego County. This Republican Party organization is highly influential in state politics and facilitates political donations and candidate support.

One of the few heroes in this report is Nikki Symington, reporter with the Borrego Sun. In the old-school tradition of small town print journalism, she has covered every local story from the annual Mother Goose Parade, to the depth of the scandal with Borrego Health.

Her exposés have not gone without severe criticism. Borrego Health brought employment to an economically depressed community. Outlays for overhead expenditures by Borrego Health supported numbers of local and regional small businesses, from car dealerships, to restaurants, to construction trade companies.

Social media in her local community of Borrego Springs went into attack mode against Symington. Some were rather vicious.

Symington responded publicly in print, “Sometimes, bad news is actually good news. Especially, when it offers an opportunity to correct illegal behavior, reconcile conflicting facts and opinions; and lead to a real community debate about the realities that will determine the future of health care in Borrego Springs.”

DISCUSSION

Nikki Symington & Borrego Sun

Dentistry Today conducted an exclusive interview with Symington. We traversed a variety of topics. As a news reporter in a smaller disadvantaged community, she is the “go to” person for local citizens to access information. She represents an historical throwback when the media held esteem and value with the public.

To follow are excerpts from that interview.

“Keep in mind the Borrego Springs clinic, which is where I can make onsite evaluations as to patient care, provides the only medical services available within a 70-mile drive to major cities – and providers. There are no private doctor’s in Borrego.”

“Well, since the large amounts of money generated from the Premier Healthcare Management/contract Dentist scam (growth of about $100 million annually over five years) wasn’t being invested in our local clinic, per our observations, the Borrego Springs Clinic has not been able to keep a local doctor on site for the past 3-years. Without a doctor with whom patients can consistently identify with and trust there is a severe loss of medical help, miscommunicated case managements, mishandled prescription requests, difficulty getting referrals, and a general lack of trust.”

Symington continued, “People in Borrego call me and ask, ‘Is the clinic open, how long will we have a clinic, is there a doctor yet?’  ‘Why isn’t the clinic answering its phone?’ Now with the bankruptcy, my usual callers have changed from people needing medical information to employees questioning me about the ‘status of their employment and benefits.'”

“The Borrego Springs clinic, the original and only FQHC, on which Borrego Health built its empire on, has been deteriorating in both primary services and medical equipment prior to the investigation. In fact, the question of how Borrego Health could make so much money and run our clinic without a nurse practitioner, mental health provider, and doctor at the beginning of COVID was what got me wondering about their finances. Also, the clinic did not even have a wheelchair, had a dead heart monitor, and other deficiencies in medical equipment and professional staff.”

“Due to the clinic’s impotence, Borrego Springs residents relied on a collection of rural paramedics to provide the original vaccines. A major loss has been the children and youth’s preventive programs that were run in coordination with the local school district, this included well health checkups and dental care. With an 80 percent Mexican population, a large percentage of parents who do not speak English, this program stressed nutrition to fight the rash of obesity, and other aspects of preventative health care that is much needed and is currently no longer available.”

Symington added, “The state and, especially, the federal monitors failed miserably. They had 10-years of seeing red flags and, admittedly, did nothing, until the Borrego Sun wouldn’t stop writing about fraud, other illegal activities, and violations of Medicaid and Medicare regulations.”

“I have asked the federal department and agencies, about their obvious role in missing such as large theft of public health insurance, and received replies copied from their websites about their programs and how they monitor… yakety yak…” continued Symington. “I am not sure this type of large-scale fraud could have happened without support from within the government. I have no proof, except issues with the state Dental Board failing to protect the public by issuing licenses and protecting dentists with court records and bad histories.”

“My other observation is: How could they be so arrogant, actually reporting the outrageous amounts dental contractors were making, (Dr. Husam Aldairi, a private dental contractor, made $8 million in 2020); listing salaries for 200 people over $100,000 and inflated wages for officers, managers, friends, and family, in their IRS 990 reports? Who would be so brazenly proud of violations of FQHC regulations unless they felt protected?” added Symington.

“All it took was reading two IRS form 990s, and the auditors’ reports, and I knew there was something wrong, and I am far from a forensic auditor, just a curious person. I am afraid, we will never know who conspired and was complicit with Borrego Health in the state and federal governments, because the governments protect their own. And that is a shame.

“Furthermore, I have a theory only, that perhaps the reason the state Department of Health Care Services wants to shut Borrego Health down quickly is, so no further investigations can link government officials.”

Symington concluded, “I would add, this investigation made me sick. The amount of greed and self-serving was insatiable. I know I have a very jaundiced view of all public health and its particular vulnerabilities to fraud, especially towards some foreign nationals.”

ABOUT THE AUTHOR

Dr. Michael W. Davis practices general dentistry in Santa Fe, NM. He also provides attorney clients with legal expert witness work and consultation. Davis also currently chairs the Santa Fe District Dental Society Peer Review Committee. He can be reached at MWDavisDDS@Comcast.net.

MM Curator summary

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

 
 

[MM Curator Summary]: Delta beat out 5 other companies. Now they just have to convince the 80% of dentists who don’t take Medicaid to sign on the dotted line.

 
 

 
 

Clipped from: https://newhampshirebulletin.com/briefs/delta-dental-would-begin-medicaid-dental-benefits-for-adults-under-33-5-million-contract/

 
 

The next challenge will be recruiting more dentists to take Medicaid. (Getty Images)

Adults insured by Medicaid may be a step closer to having their dental care covered. On Wednesday, the Executive Council will consider a $33.5 million contract with the Delta Dental Plan of New Hampshire to provide not only oral care but also oral education and transportation to appointments when needed.

The company would have until April to begin providing dental coverage to nearly 88,000 adults on Medicaid and expanded Medicaid under the 15-month contract. The state, which covers oral health care for children on Medicaid, was one of fewer than a dozen that did not also cover adults until legislation passed this year. Only emergency services were covered.

Lawmakers who have tried for more than a decade to expand benefits to adults overcame cost concerns this year by using nearly $21 million in settlement money, secured by the state against a company hired to manage Medicaid pharmacy benefits, to cover the first three years.

The next challenge will be recruiting more dentists to take Medicaid; currently fewer than 20 percent do, in part because of low reimbursement rates, tedious paperwork, and challenges caring for a population with significant health issues and difficulty showing for appointments.

Six companies submitted bids, according to documents provided to the council by the Medicaid division within the Department of Health and Human Services. The team that reviewed the bids scored Delta Dental and the other finalist, MCNA Dental, similarly on a number of program requirements, according to the documents. Delta Dental scored higher on cost savings, quality management, relevant experience, and having an adequate provider network. 

Tom Raffio, president and CEO of Northeast Delta Dental, told the Bulletin in August the company would likely submit a bid and highlight its existing relationship with nearly 851 New Hampshire dentists, 93 percent of all dentists in the state.

The new benefits would have no cap on benefits or copays for preventive services. Other dental care would be capped at $1,500 a year and require a 10 percent copay for those with household incomes above 100 percent of the federal poverty level, which is $27,750 for a family of four.

Coverage for dentures would be provided only for Medicaid recipients with developmental disabilities, acquired brain disorders, people in nursing homes, and those in the Choices for Independence program, which includes the elderly and people with chronic illness or disabilities.

MM Curator summary

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

 
 

[MM Curator Summary]: He has a point.

 
 

 
 

Clipped from: https://www.heartland.org/multimedia/podcasts/how-medicaid-compromised-long-term-care-guest-stephen-moses

Medicaid is no longer a government program to benefit the poor. It’s a system people abuse to the detriment of the long-term care market.

 
 

Poverty is no longer a requirement to qualify for long-term care under Medicaid. An entire industry has cropped up over the years instructing families on how to maximize Medicaid’s loose financial guidelines.  While families save a bundle of money by having the government now pay for this care, the system has had a negative impact on the long-term care market. Reimbursement rates under Medicaid do not cover the actual cost of care which impacts quality and supply.  Families no longer save for long term care knowing that Medicaid can come to the rescue.  Stephen Moses, president of the Center for Long-Term Care Reform, has studied long-term care for decades. He joins the show to discuss the first segment of his new report with the Paragon Institute, “Long Term Care: The Problem.”

Read the report: https://paragoninstitute.org/wp-content/uploads/2022/10/202208_Moses_LongTermCareTheProblem_FINAL_2.pdf

Seventy percent of people who reach age 65 today will require a severe need for long-term care. Long-term care provides medical and social services for those who are unable to care for themselves. 48 percent will receive paid care.  The need spikes after age 85. In ten years, the baby boomers will reach that threshold, causing demand for long-term care to soar.  Due to the loose financial guidelines, even well-off families can qualify for Medicaid coverage. This market manipulation crowds out private long-term care services. Our guest, Stephen Moses is about to release part two of a report which covers the solutions to this Medicaid problem.  His hope is that a new Congress will be open to better alternatives that improve care at more affordable prices.

In the interview, Moses discusses:

1.  How easy is it to get Medicaid to pay for long-term care?

2. How has this compromised the quality of long-term care over the decades?

3. Who will need long term care? Can any of us live independently until we die?

4. Baby boomers…most are now 65…what kind of pressure will that put on long-term care and Medicaid in 10, 20, and 30 years from now?

5. What about counting on family members to care for you? How about covering your care with your own wealth and investments?

MM Curator summary

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

 
 

[MM Curator Summary]: Translation: Hospitalling is hard, and we shouldn’t question big number mysteries.

 
 

 
 

Clipped from: https://www.thecharlottepost.com/news/2022/10/28/local-state/report-claims-nc-hospitals-made-millions-on-medicaid/

 
 

Atrium Health, the largest hospital system in North Carolina, has declared publicly that in 2019 it provided $640 million in services to Medicare patients that were never paid for, by far the largest “community benefit” it provided that year.

Like other nonprofit hospitals around the nation, Atrium logs losses on the federal health insurance program for seniors and people with disabilities as a community benefit to satisfy legal requirements for federal, state, and local tax breaks.

But for the same year that Atrium’s website says it recorded the $640 million loss on Medicare, the hospital system claimed $82 million in profits from Medicare and an additional $37.2 million in profits from Medicare Advantage in a federally required financial document, according to a report released Oct. 25 by the North Carolina state treasurer’s office.

The lack of clarity about whether health systems like Atrium gain or lose money treating Medicare recipients reflects how loosely the federal government regulates the way hospitals calculate their community benefits.

As a result, the analysis of North Carolina hospitals’ financial data concluded, what taxpayers get from local nonprofit hospitals in return for tax exemptions worth billions of dollars a year is unclear.

“There is no transparency, no accountability, and no oversight,” said North Carolina State Treasurer Dale Folwell, a Republican who is critical of Atrium and other hospitals’ business practices. “With the hospital cartel, it is always profits over people.”

Atrium did not make officials available for an interview. In a statement, spokesperson Dan Fogleman said the hospital system reported $85 million in services to Medicare patients that weren’t paid for in its most recent cost report to the Centers for Medicare & Medicaid Services.

“And, as labor, equipment, supplies and inflation continue to drive health care costs higher, the gap between Medicare payments and costs incurred to deliver the quality care we provide has grown in the post-Covid inflationary environment,” Fogleman said.

More than half of the hospitals in the United States are nonprofits or government-run. The federal government requires them to operate emergency rooms open to all patients regardless of their ability to pay, accept patients insured by Medicare, and use surplus funds to improve facilities and patient care to demonstrate they are giving back to the community.

Even though their tax-exempt status is based on charitable acts, nonprofit hospital systems sat on more than $283 billion in assets from stocks, hedge funds, venture capital, and private equity and other investments in 2019, according to a 2021 KHN analysis of IRS filings.

The hospital systems used most of that to produce income and classified only $19 billion, or about 7% of their total investments, as principally devoted to their nonprofit missions, the analysis found.

The new North Carolina report describes how hospitals’ self-reported Medicare profit margins differed from the financial picture they provided to the public through IRS records, annual reports, and community benefit documents.

Although most hospitals have complained of significant Medicare losses, the analysis of data from more than 100 North Carolina hospitals found that most made profits on Medicare from 2015 to 2020.

IRS audits are supposed to protect the public from fraud and abuse, but the system has major gaps, said health economists and federal watchdog groups.

Federal law requires the IRS to review community benefit activities at least once every three years. Yet the agency did not “have a well-documented process to ensure that those activities are being reviewed,” said a 2020 report from the Government Accountability Office.

In response to GAO recommendations, IRS leaders updated the system last year to help ensure the agency could identify cases in which hospitals were suspected of not meeting requirements.

The IRS referred nearly 1,000 hospitals nationwide to its audit division for violations of the Affordable Care Act from 2015 to 2019, but the IRS could not identify if they were related to community benefits, the GAO said.

The tax agency has no authority to determine what activities hospitals must perform to comply with the law, the GAO said. An analysis of IRS data found 30 hospitals that reported no spending on community benefits in 2016, “indicating potential noncompliance,” the report said.

“Perhaps this is the result of the IRS being underfunded,” said Vivian Ho, a health economics professor at Rice University in Houston, who worked on the North Carolina report. “They don’t have the resources to reconsider what information they should seek.”

It is critical that the government collects accurate information from hospitals because the data affects all patients, Ho said.

Federal law forbids IRS employees from discussing tax information submitted to the agency by people or organizations, IRS spokesperson Anthony Burke said in response to questions about how effectively the government monitors hospitals.

Hospitals have long used what they report as losses on Medicare to justify charging patients with private insurance higher prices. According to a study released in 2021 by the Rand Corp., a nonprofit research organization, hospitals across the nation charge private insurers more than what they receive from Medicare for the same services.

In the Affordable Care Act, federal lawmakers mandated that to maintain their tax-exempt status, nonprofit hospitals must conduct a community health needs assessment, maintain a written financial assistance policy, set billing and collections limits, and set a limit on charges.

In written responses to KHN, the North Carolina Healthcare Association, which lobbies on behalf of hospitals, said hospitals provided $1.2 billion in charity care in 2020. It added that those community benefits can include a lot of different activities, such as covering the gap between how much a procedure costs and what a provider is reimbursed, volunteering by staff, and paying for medical outreach programs.

“Providing care to vulnerable populations is part of their nonprofit mission,” the statement said.

Atrium spends millions of dollars per year to provide care to people who need behavioral health care “but have no safety net — even from the state,” the association said.
Fogleman, the Atrium spokesperson, said an advisory commission has consistently told Congress that Medicare payments do not cover the full costs of services at most hospitals, including Atrium’s.

In North Carolina, large hospital systems received $1.8 billion in tax breaks in 2020, according to the state treasurer’s office.

The same year, lobbyists for North Carolina hospitals reported collectively losing $3.1 billion on Medicare, according to the office’s report. Other data shows they made $87 million in profit.

From 2015 to 2020, the report concludes, 35 hospitals posted profits from Medicare each year.

Other hospitals listed in the report did not respond to requests for comment.

The American Hospital Association contends that the federal government reimburses providers significantly less than it costs to care for Medicare recipients. Unlike private insurers, the federal government does not negotiate prices with hospitals. Medicare bases the amount it pays on hospitals’ locations, labor costs, and other factors.

Melinda Hatton, the association’s general counsel, said in a statement that “underpayments” totaled more than $75 billion in 2020. “These data show that few, if any, hospitals break even much less make a profit on the basis of Medicare payments,” she said.

But Glenn Melnick, a health economics and finance professor at the University of Southern California who reviewed the North Carolina data, said no one is certain how nonprofit hospitals are calculating their numbers.

“The nonprofit hospital systems are getting so big, we need greater transparency,” Melnick said. “Health care is amazingly expensive, and it will bankrupt us if we don’t get it under control.”

Nonprofit hospitals receive significantly more in tax breaks than they spend on community investment or charity care, according to a report released this year by the Lown Institute, a think tank in Needham, Massachusetts.

 
 

Using 2019 data from the IRS, researchers found that out of 275 hospital systems across the country, 227 spent less on community investments or charity care than they got in tax breaks. The deficit totaled more than $18 billion, the report said.

Leah Kane is a senior attorney for consumer protection at the Charlotte Center for Legal Advocacy, a nonprofit that provides civil legal assistance to people who cannot afford an attorney. She said her agency receives calls from people who were not offered charity care from hospitals.

She said her group is worried that hospitals are offering charity care to uninsured patients but not to other people, like the underinsured, who don’t have the income to pay thousands of dollars for treatment not covered by their insurance plans.

“People are angry and stressed out,” Kane said. “They don’t know what this [debt] will mean for their lives.”

KHN correspondent Aneri Pattani contributed to this report.

Atrium Health’s response:
 

The North Carolina State Treasurer’s latest attack against health care systems is based on a flawed and incomplete analysis resulting in invalid conclusions. Atrium Health completed a detailed review of the information supplied in the report commissioned by the Treasurer’s office, and it is clear the analysis did not follow the fundamental and basic accounting principle of matching revenue and associated expenses. One example of the many inaccuracies in the Treasurer’s report is that it includes 100% of the revenues associated with lifesaving organ transplant procurement but excludes the expenses. This alone is a $39 million error in the study – at just two of our hospitals.

For abundance of clarity, Atrium Health’s certified 2020 Medicare cost reports, submitted to the Centers for Medicare & Medicaid Services, shows Atrium Health incurred unfunded costs of $85 million for care provided at our hospital facilities in North Carolina. When taking into account the full care we provided to Medicare patients in North Carolina across all care locations, including care provided within our doctor’s offices, Atrium Health incurred unfunded Medicare costs of approximately $968 million in 2020.

Our accounting is consistent with the Medicare analysis computed by DataGen, an independent organization that provides health care policy analysis. Additionally, the Medicare Payment Advisory Commission, an independent congressional agency whose membership includes leading academic and business leaders, has consistently reported to Congress that Medicare payments do not cover the cost of care provided by most hospitals, like Atrium Health.

Atrium Health is one of the largest Medicare providers in North Carolina. What we are paid by Medicare (and Medicaid) is set by the government – it is not negotiable. And, as labor, equipment, supplies and inflation continue to drive health care costs higher, the gap between Medicare payments and costs incurred to deliver care we provide has grown in the post-Covid inflationary environment. The losses we incur are a component of our audited community benefit we compile and report each year to the IRS. Atrium Health is privileged to serve our communities, providing more than $2.46 billion in free and uncompensated and undercompensated care, as well as other community benefits, last year.

Beyond Medicare, Atrium Health’s “for all” mission doubles down on providing health, hope and healing to our patients each day – regardless of their ability or inability to pay for care. In 2021, we provided over $437 million in care to more than 100,000 low income and uninsured patients who never received a bill for the care they received, with an additional 160,000 uninsured patients who automatically received discounts, totaling $150 million, thanks to our financial assistance policies that are designed to ensure access to the best care for underserved individuals and communities.

 
 

MM Curator summary

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

 
 

[MM Curator Summary]: TN nursing home moguls are hoping to use CMS requirements around access to adequate care as a cudgel.

 
 

 
 

NASHVILLE, TN — After characterizing business conditions as “never worse,” the skilled nursing sector’s top advocate said stakeholders need more help from both the federal and state governments to forge a viable path forward. 

The solution could lie in the Centers for Medicare & Medicaid Services universally demanding that states prop up Medicaid payments, said Mark Parkinson, the president and CEO of the American Health Care Association/National Center for Assisted Living, during a media briefing Tuesday at the group’s annual meeting.

“CMS has talked about really putting some teeth into its authority to require states to pay an adequate amount of Medicaid — for all healthcare providers, not just skilled nursing facilities. In far too many states right now, the reimbursement for Medicaid is dramatically less than the actual cost of taking care of people in nursing facilities,” he said.

“CMS has the power and we urge them to enforce it. Secondly, we’re going to need some help from the states. A number of states have stepped up during the pandemic and used some of the hundreds of millions of dollars that they’ve received from the federal government for providers, but unfortunately, some have not.”

Parkinson said CMS, as usual, seems to hold the key when it comes to potentially ensuring adequate Medicaid funding, which is “really what it’s all about.”

“Some pretty high level officials at CMS have started to talk about this (Medicaid adequacy rule) as a possibility in some public meetings,” Parkinson said in follow-up questioning. “The law says states have to pay an adequate Medicaid payment rate. The states’ argument has always been, as long as we have vacancies, it proves that our Medicaid rate is enough to provide access, because there are places for people to go.

“What we’re saying and what the CMS folks have been saying, there is a difference between having access to care and having access to quality care. Quality care may be more expensive than just any care, and the statute says ‘access to quality care.‘ And so they’re hinting that they’re thinking about doing something that would require states to not just show that they have empty Medicaid beds but show that people actually have access to quality care. It would be sort of like an administrative Boren Amendment. It was a statute that required states to cover the cost [of quality care]. This would be very significant if it occurred. We encourage CMS to put pressure on states to pay an adequate rate.”

CMS officials acknowledged at several public meetings this year that they were very intrigued with various models where states assume more responsibility for reimbursement.

Congress likely to help?

Parkinson and AHCA/NCAL Vice President of Government Relations Clifton Porter II addressed a wide range of issues at the media briefing, identifying — to no one’s surprise — staffing and census as top concerns. Congressional action has “ground to a halt,” Porter noted, expressing hope that a lame-duck session of Congress could give some indication by mid-December whether any helpful legislation might be in play.

In particular, he is hopeful about S4381 and HR8805, the “Ensuring Seniors’ Access to Quality Care Act,” which would essentially allow nursing centers to expand their own aide training programs. 

“(We) feel good about that,” Porter said.

That sentiment was 180 degrees from his outlook on any kind of “significant” movement on immigration reform to help ease industry staffing shortages. There are “hundreds of thousands” of would-be immigrants who could help offset the loss of at least 200,000 skilled nursing employees since the start of the pandemic, Parkinson said.

But only if they can get safely to the US, and with an approved job track. Don’t count on it any time soon, Porter said Tuesday.

“I’m not optimistic at all that there’s going to be any significant movement at all on immigration in the near term,” he said. “But we’re doing everything we can to try to impact workforce issues and challenges, bit by bit and bite by bite.”

How a minimum staffing rule could play out

Eventually, that will include a grassroots campaign to pressure CMS to issue a reasonable minimum staffing rule, which the administration has said should be expected by April.

Despite some indications of sensitivity to providers’ financial plight and bankruptcy filings with the issuance of a surprisingly generous 2023 pay rule in July, Parkinson said that it is clear the minimum staffing rule will be forthcoming and not be sidetracked by any protestations from operators, Parkinson said.

AHCA has estimated it could cost providers $10 billion annually to comply with a minimum staffing mandate of 4.1 nurse staffing hours per resident day. It also would require the recruitment of at least 100,000 more nurses — beyond the 200,000 employees skilled nursing would first need to resupply to get back up to pre-pandemic levels.

“We are hopeful when they issue the rule it will demonstrate they’ve listened to us and they’ve heard the reality. I don’t think they’re just going to back away from doing a rule. The president can’t come out and back off,” Parkinson told McKnight’s.

However, he also expressed some optimism when pointing out a handful of scenarios that could ease providers and others into new standards.

“They can issue a rule that’s paid for and/or didn’t kick in until the workforce has recovered. Maybe they’d tie it into some (Bureau of Labor Statistics) data,” Parkinson explained. 

CMS also could issue a rule “in a broad way so that the number is more achievable,” Parkinson added. This could mean widening the list of job titles that could count toward accruing direct care hours per day.

“Then the final thing that they could do is they could demo this,” he said, referring to the implementation of a demonstration project. “Maybe try a state that does have a good Medicaid rate and see what the effect is.
“They are listening to us. We talk to them frequently,” Parkinson continued. “We will have a grassroots campaign before the rule comes out. Our members are going to help them understand what the realities on the ground are.”

 
 

Clipped from: https://www.mcknights.com/news/parkinson-nursing-home-sector-pinning-hopes-on-medicaid-adequacy-rule/

 
 

MM Curator summary

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

 
 

[MM Curator Summary]: The hospital will payback 760 Medicaid members who got calls from deb collectors, with interest.

 
 

 
 

Providence Sacred Heart Medical Center is seen on July 13, 2021. Providence will reimburse Medicaid patients whose accounts were sent to debt collection agencies as part of an “unintended error,” the system announced last week as it fights a lawsuit filed by the state Attorney General’s office over charity care issues and a New York Times investigation targeting its billing practices. (Jesse Tinsley/THE SPOKESMAN-REVIEW)

Providence Health & Services will reimburse the hundreds of Medicaid patients whose accounts were sent to debt collectors when they didn’t pay, the Renton, Washington-based health care provider with hospitals in Spokane announced last week.

Citing an “unintended error,” Providence’s chief financial officer said in a statement the nonprofit would be reaching out to the roughly 760 low-income patients who should have qualified for charity care but wound up being billed. The reimbursement will include interest.

“We deeply regret that this happened and are reaching out to those who were affected and issuing repayment, including interest,” Greg Hoffman, Providence’s chief financial officer, said in a statement sent to The Spokesman-Review, along with answers to questions prompted by a New York Times investigation published last week that found patients who should have received free or discounted care were given demands for payment.

Neither Providence nor the Washington Attorney General’s Office provided an exact number of affected patients at Providence Sacred Heart or Holy Family hospitals in Spokane, two of the largest health care facilities in the region. The Washington Attorney General’s Office in February sued Providence, alleging it had denied free and discounted medical care to low-income patients in violation of state law. That included not only Medicaid patients, but households making less than 200% of the federal poverty level who should have been entitled to what’s known as “charity care” under a state law that existed between 2018 and 2021, when the alleged violations occurred.

The law has since been amended to require Providence, and other similarly sized hospital systems, to provide free or reduced cost care to patients making less than 400% of the federal poverty level. That means individual patients who make less than $54,360 annually, or a family of four earning less than $110,000, are entitled to a discount.

“Our policy exceeds those requirements,” Providence said in a statement.

The lawsuit by the state Attorney General’s Office alleges that starting in 2018, Providence sent the accounts of more than 44,000 patients making between 151% and 200% of the federal poverty level to a debt collection agency in violation of what was state law. The amount of the charges was nearly $477 million across the system, which operates hospitals in Alaska, Washington, Oregon, Montana, California and Texas.

“Providence’s practices subjected some of the most low-income and vulnerable Washingtonians to aggressive attempts to collect payment by (debt collectors),” the lawsuit alleges.

To support their claims, the attorney general’s office filed with the court emails between senior staff in December 2019 in which one financial counselor raises concern about billing practices.

“We are sending the poor to bad debt and not treating them the same as other patients that would be uninsured for the days of admit prior to Medicaid (eligibility),” the counselor wrote.

Providence is fighting the lawsuit, which was filed in King County, calling it “a gross distortion of who and what (Providence) and their caregivers are, and what they do.”

The health care system said in its statement in response to questions about billing practices that it does not engage in “aggressive tactics such as reporting accounts to credit rating agencies and garnishing wages.” The system also said it includes on every bill information about how to apply for financial assistance, also in accordance with state law.

“In alignment with our heritage, values and mission, the Providence family of organizations continues to be here for everyone, regardless of their ability to pay,” Hoffman said in his statement.

The New York Times story included testimonials from five patients, including a former employee, who said they were billed despite being eligible for discounted care. They also interviewed two former employees who said they were pressured to collect payments from impoverished patients.

Providence said it was unable to discuss the cases of four of the five patients with reporters, because Providence had not obtained a necessary waiver from the patient to discuss their private health information.

“Providence is also reaching out to each of the patients featured in the article to talk with them about their experience and ensure they have the financial assistance they need,” Hoffman said in his statement.

Providence provided charity care to 266,000 patients, totaling $1.2 billion in uncompensated costs in 2021, the provider said in its statement. Providence Sacred Heart Medical Center posted a $57 million loss in the first quarter of 2022, according to a recent Health Department report.

A hearing in the state’s lawsuit against Providence is scheduled in a King County courtroom Oct. 28.

 
 

Clipped from: https://www.spokesman.com/stories/2022/oct/02/providence-plans-to-reimburse-medicaid-recipients-/

 
 

MM Curator summary

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

 
 

[MM Curator Summary]: Florida ambulance and LTC providers are calling foul over the state’s decision to set labor costs for them.

 
 

 
 

Three Florida health care organizations and a Largo-based provider sued the state on Tuesday, arguing that state legislators illegally opened them up to class-action lawsuits if they fail to pay employees at least $15 an hour as required in the new state budget.

The lawsuit, filed in circuit court in Leon County, asks a judge to issue a temporary injunction and block the enforcement provision from taking effect. The main argument is that the Republican-controlled Legislature “logrolled” substantive issues in the annual budget, which is supposed to be limited to just budgetary matters.

The groups that filed the lawsuit against the state and the Agency for Health Care Administration (AHCA) include the Florida Ambulance and Florida Assisted Living
associations, Home Care Association of Florida and assisted living facility Heather Haven III.

The legal action targets language included in several areas of the Fiscal Year 2022-23 budget that impacts health care providers participating in the Medicaid managed care and Medicaid fee-for-service delivery systems. That language states that any employee who does not get paid $15 an hour can sue starting in January. The budget language allows employees to file class-action lawsuits.

Florida’s minimum wage currently is $10 an hour and will increase to $11 on Sept. 30. The wage will continue to increase annually by $1 until 2026 when it reaches $15 an hour. No other employer in the state can be sued for failing to pay an employee $15 per hour.

 
 

Attorneys for the plaintiffs also argue lawmakers may not have included enough money in the budget to cover the $15 wage mandate and that the risk of lawsuits could have health care providers withdrawing from the Medicaid program.

“Such an injunction will … prevent the Plaintiffs’ members and other Medicaid providers from facing the potentially crippling legal liability of class action lawsuits associated with increased pay for “direct care employees,” Tallahassee lawyer William Dean Hall III wrote in a Sept. 27 court filing.

“Ensuring that the plaintiffs Members and other Medicaid providers can reasonably continue to provide care to Floridians on Medicaid will ensure continued access to quality care for such citizens going forward.” 

In addition to the temporary injunction, the plaintiffs also are seeking declaratory relief, noting that “an actual controversy has arisen and now exists between Plaintiffs and the Defendants regarding whether the Challenged Sections are unconstitutional,” Hall wrote.

“The Plaintiffs require a judicial determination of their rights and duties in this area, specifically regarding whether the Challenged Sections amount to improper substantive lawmaking in an appropriations bill.”

 
 

Florida Politics reported the Florida Assisted Living Association sent a letter to Gov. Ron DeSantis imploring him to intervene on their behalf as the Oct. 1 minimum wage deadline for direct care providers inches closer. The Home Care Association of Florida followed with its own letter asking DeSantis to delay the $15 minimum wage requirement.

The associations noted that while they will be required to pay their direct care staff $15 an hour effective Oct. 1, the Medicaid managed care companies have not increased their reimbursement rates to offset the increased salary costs.

AHCA did not immediately respond to Florida Politics’ request for comment.

Clipped from: https://floridapolitics.com/archives/559013-medicaid-providers-ask-circuit-court-to-protect-them-from-15-minimum-wage-related-lawsuits/

 
 

MM Curator summary

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

 
 

[MM Curator Summary]: KS is turning on new payments to providers to address the workforce crunch.

 
 

 
 

(AP Photo/Eric Gay)

TOPEKA – Governor Laura Kelly today announced that her administration has begun the process of distributing $51 million in bonuses for direct care workers at Medicaid home and community-based services (HCBS) providers. Governor Kelly announced the bonus payments early this year.

The Kansas Department for Aging and Disability Services (KDADS) is disbursing the funds as one-time payments to the state’s three Managed Care Organizations (MCOs). MCOs will then disburse the funds to providers who will pay directly to their direct support staff by no later than March 30, 2023.

The distribution plan aims to serve as a tool to help recruit and retain workers; to improve access to quality services; and to increase capacity for Kansans, including those with disabilities and behavioral health challenges, to receive care in their homes and communities.

“Kansas IDD service providers have struggled to retain workers for critical direct care positions during the past several months,” InterHab Executive Director Matt Fletcher said. “The workforce bonus initiative offered through KDADS is a vital new tool for providers in attracting workers, and the IDD service system is appreciative of KDADS’s efforts to make these resources available.”

KDADS received 213 applications that will provide bonuses to 28,574 direct support workers:

• 19,067 will receive a retention bonus
  

 
 

• 12,361 full time
  
• 6,706 part-time
  

 
 

• 9,507 will receive a recruitment bonus
  

 
 

• 6,030 full time
  
• 3,477 part-time
  

Provider agencies are receiving payments based on the number of current direct care workers and immediate supervisors they employ. All funds go directly to direct service workers and their immediate supervisors. Providers are being compensated for all payroll and tax costs associated with the bonuses and $150 toward onboarding costs of new staff. Additionally, as an incentive to bring more direct support workers to the field, agencies will receive $1,500 per new staff as a recruitment bonus.

The bonus payments were made available through the American Rescue Plan Act (ARPA), signed into law in March 2021 to provide enhanced federal funding for Medicaid HCBS through a one-year 10 percent increase to the state’s Federal Medical Assistance Percentages (FMAPs). FMAPs are the percentage rates used to determine the matching federal funds allocated annually for state expenditures to social services and state and medical insurance programs.

 
 

Clipped from: https://newstalkkzrg.com/2022/09/27/kansas-has-begun-distributing-51-million-in-bonuses-to-medicaid-providers/