Tag: State News

Posted on by

TECH- Colorado Medicaid members’ data may have been stolen in cyberattack

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]: Oopsie.

 
 

 
 

Clipped from: https://www.denverpost.com/2023/06/16/colorado-medicaid-chp-moveit-cyber-attack/

Vendor used compromised MOVEit software

 
 

A laptop displays a message after being infected by a ransomware as part of a worldwide cyberattack on June 27, 2017 in Geldrop.

People covered by Medicaid or Child Health Plan Plus should take steps to protect their identities after their information likely was exposed in a cyberattack, the state agency that runs the programs said Friday.

On Thursday, several U.S. government agencies announced they’d been hit by an attack on a piece of software called MOVEit, which allows organizations to transfer large files in a way that’s similar to consumer products like Dropbox.

A criminal group called Clop has claimed responsibility and demanded extortion payments from companies, but said it didn’t mean to hit government agencies and would delete their data, according to The Washington Post. There’s no way to hold it to that promise, though.

The Colorado Department of Health Care Policy and Financing announced Friday that a vendor it worked with had used MOVEit, and there’s a good chance that Medicaid and Child Health Plan Plus members’ information may have been stolen. The department will notify individuals once it knows who was affected, it said.

The department recommended that anyone who has been covered by either program since 2015 monitor their credit reports and consider asking the credit monitoring agencies to freeze their files. It also said it’s a good idea to change passwords on your online accounts; request an Identity Protection PIN from the Internal Revenue Service so someone else can’t claim your refund; and register for a ssa.gov account if you are eligible for Social Security benefits.

Sign up for our weekly newsletter to get health news sent straight to your inbox.

Posted on by

TECH Personal data for 233,000 Iowa Medicaid members compromised in cyber attack

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]: 3 (4?) oopsies in Iowa the last year. Latest one is tied to MCNA Dental bennies.

 
 

Clipped from: https://www.thegazette.com/state-government/personal-data-for-233000-iowa-medicaid-members-compromised-in-cyber-attack/

Russian group claims responsibility

DES MOINES — More than a quarter of Iowa Medicaid patients had their personal data compromised in a data breach affecting one of Iowa’s two Dental Wellness Plan managed care organizations.

The personal information of approximately 233,000 Iowa Medicaid members was included in a data breach of MCNA Dental earlier this year, according to the Iowa Department of Health and Human Services.

It is among the largest medical data breaches in Iowa to date, according to federal data, and the largest involving Iowa Medicaid.

Advertisement

MCNA Dental, one of the largest dental insurers for government-sponsored Medicaid and CHIP programs, suffered a ransomware attack between February and March that led to unauthorized access to personal health data of nearly 9 million people, according to a filing with the Maine Attorney General.

MCNA Dental managed dental coverage under Medicaid for more than 295,000 Iowans at the end of last year, according to a report from Iowa HHS.

Delta Dental is the other managed care organization in Iowa’s dental program. It manages 486,000 Dental Wellness plans.

The Iowa Department of Health and Human Services did not respond to a request for comment by the time of publication.

What information was taken?

The hackers potentially obtained a trove of data from the managed care organization, including full names, addresses, phone numbers, Social Security numbers, driver’s license numbers, health insurance plan information, bills and insurance claims, according to a notice provided to affected patients.

The attack happened between Feb. 26 and March 7 of this year, and MCNA Dental sent notices to patients and states impacted May 26.

On Iowa Politics

You will begin to receive our Daily On Iowa Politics updates. Add erin.murphy@thegazette.com to your contacts.

The Russia-linked ransomware organization LockBit took credit for the attack and has claimed on its dark web site to have published 700 GB of patient data from MCNA, according to TechCrunch.

Who is affected?

More than 233,000 Iowans whose Medicaid dental coverage was managed by MCNA were affected. Those impacted received a notification in the mail. Names of parents, guardians or guarantors may also have been taken.

MCNA is offering free credit monitoring and identity protection services to affected individuals.

In an emailed statement, MCNA Dental said it is committed to protecting patients’ information and maintaining the integrity of its systems.

“As soon as we discovered recent unauthorized activity affecting our network, we took steps to mitigate the risk and reported the matter to law enforcement and customers,” the company said. “We continue to fortify our systems, as appropriate, to minimize the risk of a similar incident in the future.”

Other cyber incidents

The security breach is among three reported this year by Iowa Health and Human Services affecting Medicaid members.

On April 10, the department reported more than 20,000 Iowans had their data breached in an attack on an Iowa Medicaid subcontractor, Independent Living Systems.

In May, it reported Amerigroup accidentally disclosed personal health information for 8,333 Iowa Medicaid members to providers in explanation of payment notices.

Also in May, the Clarke County Hospital in Osceola reported it had been the victim of a ransomware attack, which led to the potential exposure of thousands of patients, including their names, Social Security numbers and driver’s license numbers.

Comments: cmccullough@qctimes.com

Posted on by

FINANCE- CMS Office of the Actuary Releases 2022-2031 National Health Expenditure Projections

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]: Oh lookie- another CMS crystal ball about Medicaid and Medicare future spending that no one will check to see if it came anywhere close in 10 years. But at least we feel like someone’s managing the spend, amirite?

 
 

 
 

Clipped from: https://www.cms.gov/newsroom/press-releases/cms-office-actuary-releases-2022-2031-national-health-expenditure-projections

Average annual growth in national health spending over the next decade projected to be 5.4%

The Centers for Medicare & Medicaid Services’ (CMS) Office of the Actuary released projections of National Health Expenditures (NHE) and health insurance enrollment for the years 2022-2031. The report contains expected impacts from the Inflation Reduction Act (IRA), including that people with Medicare prescription drug coverage (Part D) are projected to experience lower out-of-pocket spending on prescription drugs for 2024 and beyond as several provisions from the law begin to take effect.

CMS projects that over 2022-2031, average annual growth in NHE (5.4%) will outpace average annual growth in gross domestic product (GDP) (4.6%), resulting in an increase in the health spending share of GDP from 18.3% in 2021 to 19.6% in 2031. The insured percentage of the population is projected to have reached a historic high of 92.3% in 2022 (due to high Medicaid enrollment and gains in Marketplace coverage). It is expected to remain at that rate through 2023. Given the expiration of the Medicaid continuous enrollment condition on March 31, 2023 and the resumption of Medicaid redeterminations, Medicaid enrollment is projected to fall over 2023-2025, most notably in 2024, with an expected net loss in enrollment of 8 million beneficiaries. If current law provisions in the Affordable Care Act are allowed to expire at the end of 2025, the insured share of the population is projected to be 91.2%.  In 2031, the insured share of the population is projected to be 90.5%, similar to pre-pandemic levels.

The NHE is published annually and is often referred to as the “official” estimates of U.S. health spending and health insurance enrollment. The historical and projected estimates of NHE measure total annual U.S. spending for the delivery of health care goods and services by type of good or service (hospital, physician, prescription drugs, etc.) and by payer (private health insurance (PHI), Medicare, Medicaid, etc.).

Selected highlights on the IRA as well as NHE spending by major payer include:

Inflation Reduction Act (IRA) on Medicare Part D Enrollees: Several provisions from the IRA are expected to result in out-of-pocket savings for individuals enrolled in Medicare Part D.  Those include: i) limitations on price increases for Part D drugs beginning in 2023, ii) elimination of the cost-sharing requirement in the Part D catastrophic phase (typically 5% beneficiary coinsurance) starting in 2024, iii) implementation of a $2,000 annual cap on out-of-pocket spending on drugs under Part D beginning in 2025, and iv) reduced prices for certain high-cost drugs through negotiation resulting in lower out-of-pocket payments beginning in 2026. These provisions have notable effects on the growth rates for total out-of-pocket spending for prescription drugs, which are projected to decline by 5.9% in 2024, 4.2% in 2025, and 0.2% in 2026.

Medicare: Average annual expenditure growth of 7.5% is projected for Medicare over 2022-2031. In 2022, the combination of fee-for-service beneficiaries utilizing emergent hospital care at lower rates and the reinstatement of payment rate cuts associated with the Medicare Sequester Relief Act of 2022 resulted in slower Medicare spending growth of 4.8% (down from 8.4% in 2021). In 2025, Medicare spending is projected to grow 8.9%, reflecting the effect of the IRA’s cap ($2,000 in 2025) on out-of-pocket spending for Part D enrollees and the associated shift in responsibility for those payments that exceed the cap from the beneficiaries to the program. Projected Medicare spending growth slows to 6.8% in 2030 and 2031, associated with the IRA’s provisions related to drug price negotiations and inflation rebates, as well as slower enrollment growth as the last of the demographic cohort known as the baby boomer generation (those born between 1946-1964) enrolls in 2029.  

Medicaid:  On average, over 2022-2031, Medicaid expenditures are projected to grow by 5.0%. With the end of the continuous enrollment condition in 2023, Medicaid enrollment is projected to decline over 2023-2025, with most of the net loss in enrollment (8 million) occurring in 2024 as states resume annual Medicaid redeterminations. Medicaid enrollment is expected to increase and average less than 1% through 2031, with average expenditure growth of 5.6% over 2025-2031.  

Private Health Insurance: Over 2022-2031, private health insurance spending growth is projected to average 5.4%. Despite faster growth in private health insurance enrollment in 2022 (led by increases in Marketplace enrollment related to the American Rescue Plan Act’s subsidies), private health insurance expenditures are expected to have risen 3.0% (compared to 5.8% in 2021) due to lower utilization growth, especially for hospital services. Faster projected growth in utilization and health care prices in 2023 leads to a 7.7% increase in private health insurance spending. In 2026, private health insurance spending is expected to be impacted by the expiration of enhanced subsidies for Marketplace plans and the associated 10% decline for those enrolled in directly-purchased insurance that year.    

Selected highlights in NHE for the three largest goods and services categories include:

Overview of Hospital Trends: Over 2022-2031, hospital spending growth is expected to average 5.8% annually. In 2022, hospital spending is projected to have increased 0.8%, reflecting declines in PHI and out-of-pocket spending and low growth for Medicare, as growth in the use of hospital services slowed from higher rates in 2021. In 2023, faster growth in hospital utilization rates and accelerating growth in hospital prices (related to economywide inflation and rising labor costs) are expected to lead to faster hospital spending growth of 9.3%.  For 2025-2031, hospital spending trends are expected to normalize (with projected average annual growth of 6.1%) as there is a transition away from pandemic public health emergency funding impacts on spending.

Overview of Physician and Clinical Services Trends: Growth in physician and clinical services spending is projected to average 5.3% over 2022-2031. An expected deceleration in growth in 2022, to 2.4% from 5.6% in 2021, reflects slowing growth in the use of services following the pandemic-driven rebound in use in 2021. For 2025-2031, average spending growth for physician and clinical services is projected to be 5.7%, with an expectation that average Medicare spending growth (8.1%) for these services will exceed that of average Private Health Insurance growth (4.6%) partly as a result of comparatively faster growth in Medicare enrollment.

Overview of Retail Prescription Drugs Trends: Total expenditures for retail prescription drugs are projected to grow at an average annual rate of 4.6% over 2022-2031. Drug spending growth is projected to have slowed from 7.8% in 2021 to 5.1% in 2022, partly due to a decline in private health insurance spending, particularly on newly introduced drugs. Expenditure growth for prescription drugs in 2024 (3.7%) is similar to 2023 (3.6%). It reflects the net impacts from: i) the elimination of 5% coinsurance in the catastrophic phase in Part D, lowering out-of-pocket spending), ii) higher Medicare spending as the program absorbs a portion of out-of-pocket costs formerly paid by beneficiaries, and iii) a decline in Medicaid prescription drug spending due to 8 million in net enrollment losses. For 2025-2031, total spending growth on prescription drugs is projected to average 4.8%, reflecting the net effects of key IRA provisions: i) Part D benefit enhancements (putting upward pressure on Medicare spending growth) and ii) price negotiations/inflation rebates (putting downward pressure on Medicare and out-of-pocket spending growth). 

The Office of the Actuary’s 2022-2031 projections will be published at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html

A Health Affairs journal article from CMS’ Office of the Actuary is available here: https://www.healthaffairs.org/. To view the Health Affairs’ study on these projections, you can do so at: https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2023.00403.

###

 Get CMS news at cms.gov/newsroom, sign up for CMS news via email, and follow CMS on Twitter @CMSgov

 
 

 
 

Posted on by

PROVIDERS- The Supreme Court Delivers an Unexpected Win for 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]: Yes, Medicaid bennies – you can still sue when providers do wrong stuff. Thanks, SCOTUS!

 
 

Clipped from: https://www.medpagetoday.com/opinion/the-health-docket/105062

— An important accountability measure has been upheld

 
 

Andrew J. Twinamatsiko, JD, is an expert in health law and policy. Lawrence O. Gostin, JD, is a leading figure in national and global health law.

The Supreme Court’s decision in Health and Hospital Corporation v. Talevski , holding that beneficiaries of government entitlements can bring civil rights actions to vindicate their rights, is a major victory for millions of Americans who rely on publicly funded healthcare programs.

The justices refused to upend decades of precedent and allowed a nursing home resident’s family to sue an Indiana care home for abusing the resident. Talevski both vindicates the rights of vulnerable citizens and holds officials accountable. It affirms that Medicaid beneficiaries — some of the nation’s most vulnerable and politically powerless members — have a right to dignified care, while empowering them to sue government officials if their rights are not respected. With the recent uptick in state efforts to cut Medicaid, Talevski is a welcome assurance that the courts will remain available as a check on unfair and harmful state policies.

The Details of the Case

The case arose when Gorgi Talevski, a dementia patient at a nursing home owned by Health and Hospital Corporation of Marion County (HHC), suffered multiple abuses. HHC chemically restrained him using strong psychotropic drugs, sent him to a psychiatric facility without consulting his family, and subsequently arbitrarily discharged him. The Indiana State Department of Health failed to remedy the situation.

Talevski’s family brought a private lawsuit under 42 U.S. Code §1983opens in a new tab or window (Section 1983), a law enacted in 1871 that grants individuals the right to sue government officials and others acting “under color of state law” for civil rights violations. Section 1983 does not provide civil rights; it is a means to enforce civil rights that already exist, including Medicaid entitlements. Section 1983’s private right of action is a longstanding and important public accountability mechanism.

Talevski’s ordeal is not surprising. Abuses in nursing homes are commonopens in a new tab or window. Indeed, Congress enacted the Federal Nursing Home Reform Act (FNHRA) in 1987 to address the widespread abuse of residents. FNHRA establishes standards and oversight of nursing homes, including a residents’ bill of rights. FNHRA explicitly states that residents have a right to be free from physical and chemical restraints, and prohibits arbitrary discharge of residents.

Surprisingly, the Supreme Court agreed to hear this case even though there is longstanding precedent for bringing Section 1983 claims and there was unanimity among the circuit courts on the issue. Stakeholders were concerned that a conservative supermajority would use the case to overrule decades of precedent and undermine Medicaid.

Justice Ketanji Brown Jackson, writing for the Court, held that FNHRA unambiguously creates rights that can be vindicated using Section 1983. Jackson noted FNHRA uses “rights-creating language” that explicitly describes freedom from use of unnecessary restraints and the pre-discharge notice requirements as rights to which residents are entitled. What’s more, FNHRA requires nursing homes to respect residents’ rights, which are enforceable by individual residents. The Court rejected HHC’s argument that Congress cannot create rights enforceable under Section 1983 using its spending power, describing HHC’s arguments as “perplexing,” and grounded in “ambiguous historical evidence.”

In his dissent, Justice Clarence Thomas cited federalism concerns that suffused the Court’s reasoning in Dobbs v. Jacksonopens in a new tab or window — ending the right to an abortion — and NFIB v. Sebeliusopens in a new tab or window — striking down the Affordable Care Act’s (ACA) Medicaid expansion requirement — to argue that Spending Clause programs do not grant individual rights. Thus, Thomas would overrule the Court’s established precedents that have governed enforcement of government programs for half a century. Overruling precedent would severely curtail not only Medicaid but also a host of much needed entitlement programs such as the Children’s Health Insurance Program (CHIP), Temporary Assistance for Needy Families (TANF), and the Supplemental Nutrition Assistance Program (SNAP). Curtailing these programs would severely affect marginalized and underserved communities who already bear health burdens at a disproportionately higher rate, and thus exacerbate health disparities.

Health Implications and Takeaways

The Talevski decision is a significant victory for Medicaid beneficiaries as it keeps open the courts’ doors for vindication of federally conferred rights. The Medicaid program is vast, benefiting about 1.7 millionopens in a new tab or window nursing home residents. With at least 15,000 nursing homes across the nation, it is very difficult for the federal and state governments to maintain meaningful oversight to ensure that vulnerable members of society are receiving high quality, dignified care. The only enforcement tool the federal government has for Medicaid violations is to withhold funding, which rarely occurs.

By rebuffing HHC’s “attempts to sow renewed doubts about Section 1983’s” availability to enforce rights under the Spending Clause, the Court preserved an important accountability arrow in the Medicaid quiver. The Court’s rejection of a limited interpretation of the Spending Clause affirms a long-held principle that Medicaid benefits and other entitlements are rights, not privileges that states can take away willy-nilly. Enforcing these rights under Section 1983 gives individuals not only access to the courts but also a suite of remedies, such as injunctions, damages, and attorneys’ fees.

From a health equity standpoint — especially considering the continued worsening of health disparitiesopens in a new tab or window during the COVID-19 pandemic and states moving to purgeopens in a new tab or window their Medicaid rollsopens in a new tab or window — the Talevski decision preserves the important role Medicaid plays in closing health gaps. Since its enactment in 1965, Medicaid has been an indispensable source of access to healthcare for millions of Americansopens in a new tab or window. With the expansion of Medicaid under the ACA, Medicaid’s roleopens in a new tab or window in addressing health disparities cannot be overstated. Various vulnerable groups, comprising a disproportionate number of racial and ethnic minoritiesopens in a new tab or window, rely on Medicaid for their medical needsopens in a new tab or window, such as early screening and preventive services, family planning, inpatient and outpatient hospital care, prescription drugs, and extended institutional care for the elderly.

While the Talevski case centered around only two rights for nursing home residents, the Supreme Court’s ruling broadly encompasses a multitude of rights and welfare programs. In assuring that vulnerable individuals may rely on Section 1983, the Talevski decision will go a long way to preserve people’s rights to timely enrollment, comprehensive coverage, and eligibility determination.

Andrew Twinamatsiko, JD,opens in a new tab or window is an associate director of the Health Policy and the Law Initiative at the O’Neill Institute. Lawrence O. Gostin, JD,opens in a new tab or window is University Professor, Georgetown University’s highest academic rank, where he directs the O’Neill Institute for National & Global Health Law. He is also director of the World Health Organization Collaborating Center on National & Global Health Law. He is the author of the book, Global Health Security: A Blueprint for the Futureopens in a new tab or window.

Posted on by

PHE- Biden administration urges states to slow down on dropping people from Medicaid

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]: Please stop following the new rules and guidance we gave you on how to restart following the old rules. Or at least do it with less gusto.

 
 

Clipped from: https://www.13abc.com/2023/06/13/biden-administration-urges-states-slow-down-dropping-people-medicaid/

 
 

FILE – Health and Human Services Secretary Xavier Becerra speaks during a meeting with a task force on reproductive health care access in the Roosevelt Room of the White House, April 12, 2023, in Washington. The Biden administration on Monday, June 12, urged states to slow down their purge of Medicaid rolls, citing concerns that large numbers of lower-income people are losing health care coverage because of administrative reasons. “I am deeply concerned with the number of people unnecessarily losing coverage, especially those who appear to have lost coverage for avoidable reasons that State Medicaid offices have the power to prevent or mitigate,” Becerra wrote in a letter Monday to governors. (AP Photo/Evan Vucci, File)(AP)

By The Associated Press and DAVID A. LIEB

Published: Jun. 12, 2023 at 9:22 PM CDT

 
 

EFFERSON CITY, Mo. (AP) — The Biden administration on Monday urged states to slow down their purge of Medicaid rolls, citing concerns that large numbers of lower-income people are losing health care coverage due to administrative reasons.The nation’s Medicaid rolls swelled during the coronavirus pandemic as states were prohibited from ending people’s coverage. But that came to a halt in April, and states now must re-evaluate recipients’ eligibility — just as they had been regularly required to do before the pandemic.

In some states, about half of those whose Medicaid renewal cases were decided in April or May have lost their coverage, according to data submitted to the Centers for Medicare & Medicaid Services and obtained by The Associated Press. The primary cause is what CMS describes as “procedural reasons,” such as the failure to return forms.

“I am deeply concerned with the number of people unnecessarily losing coverage, especially those who appear to have lost coverage for avoidable reasons that State Medicaid offices have the power to prevent or mitigate,” Health and Human Services Secretary Secretary Xavier Becerra wrote in a letter Monday to governors.

Instead of immediately dropping people who haven’t responded by a deadline, federal officials are encouraging state Medicaid agencies to delay procedural terminations for one month while conducting additional targeted outreach to Medicaid recipients. Among other things, they’re also encouraging states to allow providers of managed health care plans to help people submit Medicaid renewal forms.

Nobody “should lose coverage simply because they changed addresses, didn’t receive a form, or didn’t have enough information about the renewal process,” ecerra said in a statement.

States are moving at different paces to conduct Medicaid eligibility determinations. Some haven’t dropped anyone from their rolls yet while others already have removed tens of thousands of people.

Among 18 states that reported preliminary data to CMS, about 45% of those whose renewals were due in April kept their Medicaid coverage, about 31% lost coverage and about 24% were still being processed. Of those that lost coverage, 4-out-of-5 were for procedural reasons, according to the U.S. Department of Health and Human Services.

In Arkansas, Florida, Idaho, New Hampshire and Oklahoma, about half or more of those whose eligibility cases were completed in April or May lost their Medicaid coverage, according data reviewed by the AP. Those figures may appear high because some states frontloaded the process, starting with people already deemed unlikely to remain eligible.

CMS officials have specifically highlighted concerns about Arkansas, which has dropped well over 100,000 Medicaid recipients, mostly for not returning renewal forms or requested information.

Arkansas officials said they are following a timeline under a 2021 law that requires the state to complete its redeterminations within six months of the end of the public health emergency. They said Medicaid recipients receive multiple notices — as well as texts, emails and phone calls, when possible — before being dropped. Some people probably don’t respond because they know they are no longer eligible, the state Department of Human Services said.

Republican Gov. Sarah Huckabee Sanders has dismissed criticism of the state’s redetermination process, saying Arkansas is merely getting the program back to its pre-pandemic coverage intentions.

But health care advocates said it’s particularly concerning when states have large numbers of people removed from Medicaid for not responding to re-enrollment notices.

“People who are procedurally disenrolled often are not going to realize they’ve lost coverage until they show up for a medical appointment or they go to fill their prescription and are told you no longer have insurance coverage,” said Allie Gardner, a senior research associate at the Georgetown University Center for Children and Families.

__

Associated Press writer Andrew DeMillo contributed from Little Rock, Arkansas.

Copyright 2023 The Associated Press. All rights reserved.

Most Read

 
 

From <https://www.13abc.com/2023/06/13/biden-administration-urges-states-slow-down-dropping-people-medicaid/>

 
 

 
 

Posted on by

PROVIDERS (KY)- Beshear increases Medicaid reimbursement rates for home and community-based services and long-term care facilities

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]: BlueGrass Nursing Homes will get $13M more for services already delivered in 2023 under lower rates; AND will get $100M for services in the next FY under the new rates. Where do I sign up for this deal?

 
 

 
 

Clipped from: https://www.somerset-kentucky.com/kentucky/beshear-increases-medicaid-reimbursement-rates-for-home-and-community-based-services-and-long-term-care/article_c7e7bbb4-0ac7-11ee-a55f-af46e0f6dfbf.html

 
 

Kentucky Governor Andy Beshear sits for an interview in Versailles, Ky., Wednesday, May 17, 2023.

AP Photo/Timothy D. Easley

Gov. Andy Beshear has raised Medicaid reimbursement rates for home and community-based services and long-term-care facilities to help them deal with inflation, workforce shortages and the effects of Covid-19.

“We have a duty to make sure those who need in-home care, community-based care and long-term care get the services they need and the services they deserve,” Beshear said at his weekly news conference Thursday. “This increase will provide some interim financial relief for organizations that take care of our parents and our grandparents. And right now they need our help, and we need to be there for them.”

Most of the money for the increase will come from the federal government, which funds about 70 percent of traditional Medicaid spending. The state share “is able to fit within our current appropriated budget without the need for additional state funds,” said Susan Dunlap, spokeswoman for the Cabinet for Health and Family Services. “The current Medicaid spending trends allow the cabinet access to funds to increase the Medicaid rate.”

Dunlap noted that the cabinet “is required to adjust price-based nursing facility rates for inflation every July 1. During the budget process, the cabinet accounts for an inflationary increase in our projections for the inflationary adjustment.”

The nursing-home adjustments are retroactive, to make up for underestimated inflationary increases that were provided in the last three years, Beshear said. This will result in $99.6 million more for nursing homes in the next fiscal year, which ends June 30, 2024. The state’s share will be $18.9 million.

The adjustment for home and community-based services will be for services that were delivered from Jan. 1, 2022, to May 1, 2023, at an additional cost of $13 million, according to a news release.

The main lobbying group for nursing homes and assisted-living facilities told Kentucky Health News that it is expecting an overall adjustment of about 8 percent, and that it will vary from facility to facility.

Betsy Johnson, president of the Kentucky Association of Health Care Facilities and Kentucky Center for Assisted Living, praised the governor’s action, calling it “welcome relief” for struggling long-term care facilities that have been sounding the alarm about the skyrocketing costs required to keep their residents and patients safe and healthy.

“We are grateful for Gov. Beshear and his administration,” Johnson said. “The pandemic had devastating effects and worsened the staffing crisis we were already facing. This funding will be paramount to providing quality care to residents and patients as well as building the foundation for a brighter future.”

John Muller, chief operating officer for Carespring Healthcare Management in Northern Kentucky, thanked Beshear and his team at the news conference. Muller is also a KAHCF board member.

“Nursing facilities were on the front lines of the Covid pandemic. The last number of years have been very, very difficult,” Muller said. “And as we are coming out of the pandemic, the aftershock is the workforce challenges that we’re facing. Nursing facilities are lagging far behind on catching up in the workforce. These much-needed funds will go a long way for the residents we serve . . . as well as the team members we need to retain and the new ones we need to recruit.”

David McKenzie, administrator and owner of The Jordan Center in Louisa, conveyed an urgent need for these increased funds in a letter to Health and Family Services Secretary Eric Friedlander on March 28,

McKenzie painted a picture of his facility’s dire financial situation and asked for a “funding bridge” to allow nursing homes to survive until July 1, 2024, when their rates are scheduled to be recalculated.

“Our facility will not make it if we don’t receive a funding bridge July 1, 2023,” he wrote. “We have never seen price increases like this in our 49 years of business! In February 2022, we had to close half of our facility because we only had enough staff to operate 60 beds and maintain our 5-star staffing rating.”

Emily Webber, KAHCF director of communications, said the additional funding will go a long way to help pay for supplies, operational costs and staffing, noting that long-term care facilities are still one of the health-care sectors that have not recovered from the staffing shortages caused by the pandemic.

Beshear has also committed to rebasing the Medicaid rate effective July 1, 2024, but that would require appropriations from the General Assembly next year, and Beshear’s term will end late this year unless the voters given him a second four-year term in the Nov. 7 election.

“We’re dealing with an election. We’re dealing with a budget session. So there are lots of things for us to address,” Johnson said. “But as you just stated, right now, where it stands, we understand that the current administration and the Kentucky legislature are very sympathetic to our challenges and we believe that we can all work together so that this money will be appropriated.”

Johnson said her members are “thrilled” because they have not seen a Medicaid raise since 2008 and are now operating in a completely different world.

“This funding is a good first step toward getting us back on our feet,” she said, adding later, “If you ask any one of our member providers, when we say, ‘Oh, post-pandemic world or post-Covid,’ they will look you in the eye and say, ‘Betsy, we’re still in it’ because the struggles are real. It has forever changed the way they operate and the staff that they need. It’s very, very important that we should all, as Kentuckians, be invested in this taking care of our elderly, and our most vulnerable citizens.”

Posted on by

PHE- Fiscal Implications for Medicaid of Enhanced Federal Funding and Continuous Enrollment

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 PHE added about $117B in fed money via the increased FMAP. Did it go to clear waiting lists? Did it go to increase provider rates? Or maybe it went to ACA-ish rate cells? With the witchcraft that is Medicaid math- We may never know (and we seem to like it that way).

 
 

 
 

Clipped from: https://www.kff.org/medicaid/issue-brief/fiscal-implications-for-medicaid-of-enhanced-federal-funding-and-continuous-enrollment/

For a three-year period, states provided continuous enrollment in Medicaid in exchange for an increase in the percentage of Medicaid spending that is paid for by the federal government (the Federal Medical Assistance Percentage or “FMAP”). A recent KFF analysis estimated that over 23 million people gained Medicaid coverage during the continuous enrollment period. Beginning April 1, 2023, states could begin disenrolling individuals from Medicaid, but phased-down federal matching funds will be available through the end of the year if states comply with certain rules. While there remains a great deal of uncertainty as to how Medicaid enrollment will change during the unwinding, the end of the Medicaid continuous enrollment provision and enhanced FMAP are expected to have a significant impact on Medicaid enrollment and spending. This brief examines how Medicaid spending changed during the continuous enrollment period and estimates the amount of enhanced federal funding states received during the continuous enrollment period. Key findings include:

  • State spending dipped below pre-pandemic levels even as Medicaid enrollment increased by 23 million during the continuous enrollment period. With the substantial enrollment growth, total spending increased, including significant increases in federal Medicaid spending due to the enhanced FMAP.
  • We estimate states received over $117 billion from the increased FMAP during the continuous enrollment period, with enhanced federal funds comprising a larger share of total Medicaid spending in states that had not adopted Medicaid expansion through the Affordable Care Act (ACA).
  • Although the magnitude is uncertain, significant decreases in Medicaid enrollment are expected during the unwinding of the continuous enrollment provision, which will result in lower Medicaid spending. Even with lower enrollment, state spending will likely increase as the enhanced FMAP expires.
  • The phase down of the enhanced FMAP was designed to provide continued financial support to states during the unwinding process and to mitigate sharp increases in state Medicaid spending. How much state Medicaid spending increases as the enhanced FMAP phases down and is ultimately eliminated next year will depend on how many and how quickly people are disenrolled, how many new people come on to Medicaid, and how spending per person in the Medicaid program will change.

What was the purpose of the enhanced federal Medicaid match rate?

States received a 6.2 percentage point FMAP increase in exchange for keeping individuals continuously enrolled during the pandemic as authorized by the Families First Coronavirus Response Act (FFCRA). The increased FMAP was retroactive to January 1, 2020 and generally applied to Medicaid spending that would otherwise reimbursed at the state’s regular FMAP. The enhanced federal matching funds do not apply to administrative expenses or to Medicaid spending that is already subject to an increased match, including spending for ACA expansion adults (the FMAP is 90% for adults eligible through expansion). The Consolidated Appropriations Act, 2023 (CAA) delinked the continuous enrollment provision from the public health emergency (PHE), ending continuous enrollment on March 31, 2023. The CAA also phases down the enhanced federal Medicaid matching funds through December 2023, with the increased FMAP decreasing to 5 percentage points from April to June 2023, 2.5 percentage points from June to September 2023, and 1.5 percentage points from October to December 2023.

The federal funding from the enhanced FMAP was designed to support the costs of increased Medicaid enrollment and provide fiscal relief to states beyond the costs of enrollment growth. During economic downturns, enrollment in Medicaid grows, increasing state Medicaid costs while state tax revenues are declining. Congress enacted legislation to temporarily increase the federal share of Medicaid during the last two economic downturns prior to the pandemic. At the onset of the COVID-19 pandemic, states were projecting large revenue declines, but the enhanced FMAP provided new federal funding to states quickly by using an existing federal funding mechanism. Enhanced federal funding supported state Medicaid programs and helped free up state funds for other purposes including mitigating the need for widespread spending cuts on other services and filling gaps in state budget shortfalls.

How did Medicaid spending change during the pandemic?

State spending on Medicaid dipped below pre-pandemic levels even as enrollment in Medicaid increased by 23 million during the continuous enrollment period (Figure 1). The reduction in state spending reflected a sharp drop from $231 billion in 2019 to $214 billion in FY 2020, accompanied by an increase in federal spending of nearly $50 billion (from $393 billion to $444 billion). After 2020, state spending remained relatively stable while federal spending continued to increase due to the enhanced FMAP and total spending increased in conjunction with rising enrollment. State spending remained below 2019 levels in both expansion (defined as those having implemented Medicaid expansion as of 10/1/2021) and non-expansion states through the end of FY 2022. In the first six months of FY 2023—before the end of the continuous enrollment provision—we find that total and federal spending continued to increase while state spending returned to levels similar to the first two quarters of 2019. We expect spending and enrollment levels for the second half of 2023 to change, reflecting the end of the continuous enrollment period.

How much did states receive in enhanced federal funding during the continuous enrollment period?

During the continuous enrollment period, we estimate that states received over $117 billion in funding from the increased FMAP, with non-expansion states receiving a disproportionate share (Figure 2 and Appendix Table 1). Non-expansion states received 27% of the enhanced funding despite accounting for only 22% of all Medicaid spending because the enhanced FMAP does not apply to spending for people eligible through an ACA expansion. Across all states, the $117 billion in additional funding comprised an estimated 5% of total Medicaid spending and 7% of federal Medicaid spending during the continuous enrollment period (January 2020 through March 2023).

What might happen to Medicaid spending during the unwinding?

Although the size of the effects are quite uncertain, significant decreases in Medicaid enrollment are expected during the 14-month period in which states unwind the continuous enrollment period. KFF estimates that nationally Medicaid enrollment will decrease by 18% (17 million people) between March 2023 and May 2024 (based on a recent survey of states), but in practice, rates of enrollment decline will vary across states, depending on states’ approaches to unwinding. Early data from states shows substantial variation in disenrollment rates. While state Medicaid agencies report enrollment changes as the most significant factor driving changes in total Medicaid spending, they also note that factors such provider payment rate increases were putting upward pressure on spending. Overall, total Medicaid spending could decrease during the unwinding if the effects of enrollment losses are larger than the effects of other factors such as those.

Even with declining enrollment, state spending on Medicaid will likely increase as the enhanced FMAP expires. States are expecting the end of the enhanced FMAP to shift the state and federal spending shares, as has been the case in previous economic downturns when an enhanced FMAP expired. CBO estimates that federal spending will decrease by about 9% from FY 2023 to FY 2024. While states received substantial enhanced federal funding of $117 billion during the continuous enrollment period, they will likely see increases in state Medicaid spending as the enhanced federal matching funds expire at the end of the year.

The phase down of the enhanced FMAP was designed to provide continued financial support to states during the unwinding process and to mitigate sharp increases in state Medicaid spending. Before the CAA delinked the continuous enrollment provision and the enhanced FMAP from the PHE, the enhanced FMAP was set to expire at the end of the quarter when the PHE expired. The gradual phase-out of the FMAP through December 2023 recognizes that it will take states time to unwind the continuous enrollment provision and conduct redeterminations for all Medicaid enrollees. To be eligible for the enhanced match, states must meet certain eligibility, renewal, and reporting requirements. Recently, in a letter to CMS, Democratic lawmakers reiterated these beneficiary protections as well as CMS enforcement tools that were made available in the CAA, and CMS, in a letter to state governors, reiterated that states must comply with federal requirements to continue to draw down enhanced federal funds. The amount of the enhanced funding available to states during the unwinding will be smaller relative to the continuous-enrollment period, but it will still help mitigate the shift in funding from the federal government back to the states. As the enhanced federal funding is phased out and ultimately eliminated, the size of the increase in state Medicaid spending will depend on changes in total spending growth, which in turn will reflect how quickly people are disenrolled, how many new people come on to Medicaid, and how spending per person in the Medicaid program will change. These enrollment and spending changes will vary by state.

Appendix

Methods

Data: This analysis uses the Medicaid CMS-64 new adult group expenditure data collected through MBES (CMS-64 data), the 2019 T-MSIS Research Identifiable Demographic-Eligibility and Claims Files (T-MSIS data), the May 2023 Congressional Budget Office (CBO) estimates of federal Medicaid spending per enrollee, and enrollment estimates from a prior KFF analysis.

Overview of Approach: To estimate total, federal, and state Medicaid spending as well as the enhanced federal funding states received from the increased FMAP, we:

  • Use estimates of Medicaid enrollment by eligibility group during the continuous enrollment period, which are described in the prior analysis,
  • Use actual total Medicaid expenditure data from CMS-64 and the ratio of per enrollee spending by eligibility group from T-MSIS to estimate per enrollee spending by eligibility group for FY 2019 – FY 2022,
  • Estimate spending per enrollee for FY 2023 by growing the previous year’s per enrollee spending for each eligibility group based on the CBO’s projected Medicaid spending per enrollee,
  • Calculate total, federal, and state spending during the pandemic based on a state’s actual FMAP, and
  • Compare to an estimate of what state spending would have been without the FMAP increase to estimate enhanced federal funding.

Definitions and Limitations: While very similar at a national level, our estimates of the enhanced federal funding received over the period do not match those posted by the Medicaid CMS-64 FFCRA Increased FMAP Expenditure reports. There are a few reasons for this:

  • We estimate total additional federal funds for the continuous enrollment period (through March 2023), while the FFCRA expenditure reports only showed spending through June 2022 as of May 2023, when the analysis was completed.
  • Our estimates reflect an accrual basis of accounting—which means we estimate all spending states incurred each quarter. In practice, states have two years following the date a service was rendered to report their spending, so some spending so the FFRCA reports will not show complete spending until two years after the enhanced FMAP ends. If the FFCRA expenditure reports show spending when it is paid from the federal government to the states—rather than when states incurred the costs, the timing of federal payments will be different from what we have estimated.
  • Our model assumes the 6.2 percentage point FMAP increase applies to all non-administrative Medicaid spending for enrollees that are not ACA expansion enrollees. While they usually account for only a small share of overall spending, we do not make additional exclusions for the other services that are matched at a higher rate, which include family planning, services received through an Indian Health Services facility, expenditures for Medicare beneficiaries enrolled in the “Qualifying Individuals” program, and home health services that are matched at a 90% rate.

We provide more detail about each step in the process below.

1. Estimate Medicaid enrollment by eligibility group.

  • For enrollment by eligibility group through the end of the continuous enrollment period, we use estimates from a previous KFF analysis.

2. Prepare CMS-64 expenditure data and estimate spending per enrollee by eligibility group for FY 2019 – FY 2022 at the state level.

  • First, we pull quarterly data from the Medicaid CMS-64 New Adults Group Expenditure Data collected through MBES and aggregate total and federal spending by state for enrollees in the ACA expansion group and for all other Medicaid enrollees from FY 2019 – FY 2022. Spending includes all medical assistance expenditures.
  • Data for FY 2022 was only available for three of the four quarters (through June 2022). We assume those expenditures constitute 75% of FY 2022 spending to estimate expenditures for the full year.
  • We calculate spending per enrollee for each FY for the ACA expansion group and all other enrollees by dividing the group’s total spending by the enrollment in September of that year.
  • We use the 2019 T-MSIS claims data to estimate spending per enrollee for the non-expansion enrollees. We calculate the ratio of spending per enrollees for each specific eligibility group to spending per enrollee for all non-expansion enrollees. We apply these ratios to the spending per enrollee from the CMS-64 data for all non-expansion enrollees to estimate spending per enrollee for each eligibility group.
  • We scale state-level spending per enrollee by eligibility group estimates so that multiplying enrollment by spending per enrollee equals the total spending in each state from the CMS 64 in FY 2019 – FY 2022.

3. Estimate FY 2023 spending per enrollee. We only have full-year, detailed administrative expenditure data through June 2022, so we estimated expenditures for FY 2023.

  • We use the CBO’s May 2023 projections of average federal spending on benefit payments per enrollee by eligibility group and their assumed FMAPs to estimate average total spending per enrollee by eligibility group for FY 2022 and FY 2023.
  • We calculate the growth in total spending per enrollee from FY 2022 to FY 2023 by eligibility group and apply the 2023 growth rates to our 2022 estimated spending per enrollee, resulting in estimated spending per enrollee by eligibility group for 2023.
  • For states that newly expanded Medicaid, we estimated spending per enrollee for the new group by multiplying that state’s spending per enrollee for their non-expansion adults by the ratio of spending per expansion enrollee to non-expansion enrollee in all other states.

4. Calculate total, federal, and state Medicaid spending during the pandemic with the enhanced FMAP.

  • For each FY, we estimate total Medicaid spending by multiplying spending per enrollee by enrollment. We group spending into two groups: spending on ACA expansion group and spending for all other Medicaid enrollees.
  • We estimate the FMAPs as the percentage of total spending that is federal spending in the CMS-64. We assume the FY 2022 FMAP applies for the rest of the continuous enrollment period, which is the first six months of FY 2023.

5.  Estimate enhanced federal funding.

  • We estimate states’ spending without the enhanced FMAP by subtracting 6.2 percentage points from each state’s FMAP for non-expansion spending.
  • Total spending from the enhanced FMAP is estimated to be the difference between states’ actual spending and the spending we estimated without the enhanced FMAP.
  • The American Rescue Plan Act included a 5-percentage point increase in the FMAP for states to adopt an ACA Medicaid expansion. For the states using this option during the continuous enrollment period (Missouri and Oklahoma), we subtracted the enhanced federal funding from that provision from state spending when calculating spending from the continuous enrollment enhanced FMAP.

 
 

Posted on by

FWA (NY)- NY brings fresh allegations of a for-profit nursing home “pocketing” Medicaid funds

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]: Uri and Efraim are on the NY AG naughty list for $38M in no-nos. Related- the state has been watching these dudes since 2017. But lets not ask why its taken 6 years to get the case to this point.

 
 

Clipped from: https://www.mcknights.com/news/ny-brings-fresh-allegations-of-a-for-profit-nursing-home-pocketing-medicaid-funds/

 
 

 
 

New York’s attorney general wants a state court to force the owners of a Syracuse nursing home to answer questions about “pocketing” $37.6 million in government funding, while the accused’s attorneys say such related-party transactions and other suspect business transactions are common and acceptable. 

Uri Koenig and Efraim Steif, owners of Van Duyn Center for Rehabilitation and Nursing, face numerous allegations of diverting Medicaid funds for their own financial gain, inadequate staffing, and neglect. NY Attorney General Letitia James’ office also alleges that the owners are intentionally “keeping staffing levels low,” according to a June 7 court filing asking the New York Supreme Court order to compel the owners to talk.

The case is the latest in the AG’s quest to spotlight what she considers predatory and illegal financial practices that have in some cases led to reduced staffing and serious patient care concerns. This is at least the fourth case James has pursued against for-profit owners since November of 2022.

In November, James sued the owners and operators of Comprehensive at Orleans LLC, doing business as The Villages of Orleans Health and Rehabilitation Center, a 120-bed nursing home in upstate New York, alleging the illegally diverted $18.6 million in Medicare and Medicaid funds. In December, she filed similar cases against Cold Spring Hills Center for Nursing and Rehabilitation and Fulton Commons Care Center, both located on Long Island.

The most recent Medicaid case demonstrates the lengths some states are going to to rein in regularly used business practices amid an equally aggressive pursuit by federal regulators to bring transparency to the nursing home sector.

“The Attorney General should be permitted to question Respondents about these financial arrangements, which served to siphon government funds from their intended purpose of supporting required resident care,” says a filing the AG’s office shared with McKnight’s Long-Term Care News on Friday.

“The policies that keep staffing levels low and resident census high appear to stem from decisions made by those who control Van Duyn’s operations and business decisions, including Respondent owners,” the filing added. “This is further supported by financial documents demonstrating that Respondent owners diverted money away from resident care and into their pockets by way of disbursements and related company transactions.”

The filing notes that the 513-bed facility has 78 citations from the state Department of Health, including two pertaining to Actual Harm or Immediate Jeopardy. The facility has been a candidate for placement on the Special Focus Facility list, which denotes the poorest performers in the country, since 2018, officials added. The Attorney General’s Medicaid Fraud Control Unit initially opened an investigation into Van Duyne in late 2017, the filing said. 

“[The] investigation has also shown that, during the period of Van Duyn’s poor performance, significant fund transfers out of the nursing home, whereby Respondents funneled millions of dollars paid to Van Duyn by government programs for resident care to themselves and related party companies,” the court document said. “Indeed, a non-profit organization’s analysis found that Van Duyn’s owners routinely engage in related company transactions designed to siphon taxpayer funds away from resident care.”

According to the court document, Koenig and Steif either “own or are strongly affiliated” with related parties that conduct business with the nursing home, including Upstate Services Group, LLC, which provides administrative consulting services to Van Duyn; Fiscal Care, LLC, which provides Van Duyn’s billing services; CFare Foods, LLC, which provides Van Duyn’s food services. Koenig and Steif also control all or part of the company to which the facility pays a “vastly inflated rent,” the document said. 

David R. Ross, an attorney with O’Connell and Aronowitz, however, said the owners intend to provide a response to the Attorney General’s office showing that the way Van Duyn conducts business is in accordance with state regulations. 

“Related party transactions are the norm, as they create economies of scale and resulting cost savings which benefit everyone,” Ross said in a statement to McKnight’s. “These related party transactions are standard practices that are commonplace in New York State and throughout the country, and are characteristic of for-profit and nonprofit nursing homes, as well as hospitals. All related party transactions are fully transparent and are required to be, and have been, reported to the New York State Department of Health in annual cost reports.”

Posted on by

FWA (OH)- Owner of Eye for Change sentenced in $3.4M Medicaid fraud

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]: Alfonzo and 20 of his employees used a bogus counseling company to steal $3.4M of your tax dollars. Medicaid members also took kickbacks to help make it all work. They did not say thank you.

 
 

 
 

Clipped from: https://fox8.com/news/3-4m-judgment-in-cleveland-medicaid-fraud-case/

[In the player above, get a breakdown of the top stories on FOX8.com for Tuesday, June 13, 2023.]

CLEVELAND (WJW) — The owner of a Cleveland nonprofit offering mental health counseling, which for years defrauded Medicaid by filing fake claims, will spend three years in prison and must repay $3.4 million, a federal judge ruled Tuesday.

Alfonzo Bailey, 40, of Euclid, who founded Eye for Change Youth and Family Services in 2016, pleaded guilty Tuesday to conspiracy to commit healthcare fraud, according to a news release from U.S. Attorney Rebecca Lutzko of Ohio’s Northern District Court.

Suspect flees after armed robbery at University Hospitals

He was sentenced to 36 months in prison and ordered to pay $3,465,643 in restitution for the scheme, in which the nonprofit’s employees conspired to bill the Ohio Department of Medicaid for services that were never rendered according to the U.S. attorney’s office.

The nonprofit Eye for Change offered mental health counseling, case management, job training and supportive housing, among other services, according to the release.

A superseding indictment handed up in May 2021
charged Bailey, the nonprofit and 20 employees with healthcare fraud, money laundering and other related charges in the scheme, which lasted from February 2017 to September 2020.

Prosecutors alleged employees were directed to misdiagnose Medicaid beneficiaries, seeking authorization from the state Medicaid department to offer services at increased rates. Some employees submitted false notes to show proof of the services, according to prosecutors.

Others were accused of paying kickbacks including cash, gift cards and rent or bill payments to those Medicaid beneficiaries, in order to add them to the nonprofit’s clientele, then sending more fraudulent bills to Medicaid.

“These individuals engaged in a scheme to defraud taxpayers by submitting fraudulent billing to a federally funded healthcare program, which is supported by hard-working citizens,” FBI Special Agent in Charge Eric Smith is quoted in a news release from November 2020, when Bailey and eight others were initially indicted.

Growing homeless community causing concern in Cleveland

At the time, Eye for Change was associated with properties in Cleveland, Cleveland Heights and Columbus, according to the 2020 news release.

“There are actually real people out there who are suffering and need help,” Attorney General Dave Yost said at the time.  “You don’t have to make up imaginary patients. A jury of their peers will undoubtedly know some of them. I’m grateful for the state-federal partnership that is bringing these fakes to justice.”

Posted on by

FWA (NC)- Eastern District of North Carolina | Fayetteville Cardiologist Agrees to Pay Over $5 Million to Resolve Allegedly False Medicare and Medicaid Claims

MM Curator summary

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

 
 

[MM Curator Summary]: Hari did lots of unnecessary cardiac procedures to steal $5M of your tax dollars. He did not say thank you.

 
 

 
 

Clipped from: https://www.justice.gov/usao-ednc/pr/fayetteville-cardiologist-agrees-pay-over-5-million-resolve-allegedly-false-medicare

RALEIGH, N.C. – Fayetteville, North Carolina cardiologist Dr. Hari Saini and his current practice, Carolina Heart and Leg Center, P.A., agreed to pay $5,015,554 to the United States and North Carolina to resolve allegedly false Medicare and Medicaid claims. 

“This civil fraud settlement demonstrates our steadfast commitment to protect taxpayer money and guard the integrity of our vital health care programs,” said U.S. Attorney Michael Easley.  “Medical doctors should never bill for unnecessary procedures.  Those who do will be held accountable.  Our office will zealously pursue damages and civil penalties against medical professionals where warranted.”

This settlement arose from whistleblower allegations that Dr. Saini and his cardiology practice performed unnecessary atherectomy procedures to remove minor plaque blockage in leg arteries in patients.  The United States filed a complaint against Dr. Saini, Carolina Heart and Leg Center, and Carolina Cape Fear Medical Group, alleging that Defendants “systematically overstated the stenosis percentage” to justify medically unnecessary atherectomies for the maximum number of procedures for their patients. More specifically, the Government alleged that Dr. Saini—who was one of the highest billing cardiologists in North Carolina for this type of claim—conducted “risky and invasive atherectomy procedures to unnecessarily remove plaque blockage that was, at best, only minimally present, all in blatant disregard for patient safety and Program billing requirements.”  Based upon billing and medical records, Defendants were paid millions from Medicare and Medicaid, which the Government alleged was not supported by the retained medical records for the services provided and billed. 

Ultimately, after six years of discovery and litigation, and with trial looming, Dr. Saini and his practice agreed to pay more than $5 million to resolve the False Claims Act allegations. 

“Physicians cannot perform procedures on patients who don’t need them just to make more money,” said Attorney General Josh Stein. “That’s a waste of taxpayer resources and a fundamental abuse of the trust we put in doctors. My office will hold accountable health care providers when they commit fraud for their own enrichment.”

The federal and state False Claims Acts mandate that the Governments recover triple the money falsely obtained, plus substantial penalties for each false claim submitted, and attorneys’ fees and costs to the whistleblower.  It should be noted that the civil claims resolved by settlement here are allegations only, and that there has been no judicial determination or admission of liability.  Dr. Saini and his practice deny these fraud allegations.

This matter was handled in partnership between the United States Attorney’s Office of the Eastern District of North Carolina and the Medicaid Investigations Division of the North Carolina Attorney General’s Office.  Assistant United States Attorney Neal Fowler and North Carolina Senior Deputy Attorney General Eddie Kirby represented the United States and State of North Carolina in this civil action.  The investigation was conducted by the HHS Office of Inspector General, including Special Agent Craig Schiffbauer, and the North Carolina Medicaid Investigations Division.