Tag: State News

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SD- Gov. Kristi Noem, state departments begin process to implement ‘will of the voters’ in Medicaid expansion

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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]: SD officials grudgingly begin to implement the expansion approved by the 3rd estate.

 
 

Clipped from: https://www.mitchellrepublic.com/news/south-dakota/gov-kristi-noem-state-departments-begin-process-to-implement-will-of-the-voters-in-medicaid-expansion

After passing with 56% of the vote, offering Medicaid benefits to an expanded population is now a part of the state constitution. Here’s what state officials have to do to meet the July 1 deadline.

 
 

House Speaker Hugh Bartels stands to applaud during Gov. Kristi Noem’s budget address on Dec. 6. Part of the new spending in Noem’s budget was $13 million this year to begin implementing the Medicaid expansion passed by the voters on Nov. 8, 2022.

Jason Harward / Forum News Service

SIOUX FALLS, S.D. — With language now etched into the South Dakota State Constitution requiring the state to provide Medicaid benefits to an expanded eligibility group, Gov. Kristi Noem and the state legislature are indicating they will implement the amendment as written.

“The legislature’s hands are tied,” said Rep. Kevin Jensen, who will chair the House Health and Human Services Committee this coming session. “Because of the constitutional amendment, we can’t do anything to change or restrict it other than pass another amendment. So the legislature, as far as I can see, our only role will be to either vote for the funding bill at the end of the year or vote against it.”

Timeline requires enrollments by July

The language of Initiated Amendment D, which passed with 56% of the vote on Nov. 8, makes clear the general process ahead of the Department of Social Services, which will oversee the expansion of Medicaid to adults between the ages of 18 and 64 with incomes below 138.5% of the federal poverty line.

By March 1, 2023, the department must submit an amended state plan to the federal divisions that oversee Medicaid. In a statement to Forum News Service, Laurie Gil, the secretary of the state Department of Social Services (DSS), said these amendments “will establish eligibility, benefits, and the delivery system for the expansion population.”

The amendment then requires that the program begin accepting applications and conferring these benefits on July 1, 2023.

“DSS currently anticipates accepting applications in July 2023, and we plan to communicate a more specific date for accepting applications in late spring 2023,” Gil wrote in the statement.

As currently constructed, the federal government covers 90% of health care costs incurred by those in the expansion population — according to the Bureau of Finance and Management,
52,000 South Dakotans are expected to be eligible for the program.

During the first two years of expansion, the federal government offers states a boost in funding as an incentive; these incentives are estimated to total $53 million in the first year.

On top of these incentives meant to offset parts of the initial cost, Noem during her budget address on Dec. 6 proposed an appropriation of just under $13 million in the first year of expansion.

South Dakota

Gov. Kristi Noem delivers South Dakota budget address, headlined by grocery tax cut, strong revenues

The budget, which features a topline dollar figure of $7.2 billion, makes investments in state employees, providers and the state’s correctional infrastructure. Noem will look to push her proposals through the legislature, which has final say on all spending matters.

December 06, 2022 03:55 PM

 · 

By  Jason Harward

The Bureau of Finance and Management says this will cover an additional 68 full-time DSS employees to administer expansion and “includes additional contingency funding on both healthcare cost and projected enrollment.”

Opposition could inform legislative actions

Even in appropriating those dollars, Noem continued to make clear her opposition to the program itself.

“Make no mistake, the expansion of Medicaid — as passed on the November ballot by the people of this state — is an expansion of a government program that will give free healthcare to a population of the state that the majority are able-bodied, single males,” Noem said.

While this statement is generally true when looking at state-level data (in Maine, for example, more than 86% of enrollees as of Oct. 1 are childless adults, 54% of whom are male), some legislators think that the economics of the program still make sense for the state.

“From a practical standpoint, these folks are the working poor,” said Sen. Sydney Davis, who will serve as the vice chair of the Senate Health and Human Services committee this session. “They have no resources for preventative health care, so they end up in the emergency room, with conditions that could have easily been prevented, and that is likely to now be more costly.”

Noem disagrees, saying during her speech that “costs exceeded their expectations” in every other state that has expanded Medicaid, a point that several legislators concur with. Noem estimated that, in the fifth year of implementation, the state would bear a cost of $80 million.

“A lot of people fear it could lead to a state income tax because at some point it’s going to cost us $100 million per year,” Rep. Kevin Jensen said.

Although enrollment does often exceed expectations, several states report savings in other areas of the general fund that make up for part of these overruns. In Montana, for example, direct savings from Medicaid expansion in 2021 totaled $27 million, largely from new federal dollars covering other state expenses

South Dakota’s Legislative Research Council estimated these savings at around $11 million per year, with the offsets mainly coming from “correctional healthcare, behavioral healthcare, and Indian Health services.”

Another concern for legislators is the potential for the federal government to change its end of the 90-10 cost share, which would not change South Dakota’s constitutional mandate and would simply increase the cost borne by the state.

Sen. Jean Hunhoff, the chair of the appropriations committee in the Senate, told Forum News Service in November that it might be wise for the state to save some of the federal dollar incentives coming into the state during the first two years to cover this potential risk.

“We would have to pick up all that extra that [federal dollars] were no longer picking up,” Hunhoff said. “I think we have to see how we can manage those dollars that are coming in and make sure those dollars go into a fund that is to cover a Medicaid expansion group.”

An additional ancillary appropriation that could increase enrollment would be some amount of one-time funding for outreach and education. While Shelly Ten Napel, the executive director of the Community HealthCare Association of the Dakotas, said efforts like these have had “really significant impacts” on enrollment rates in other states, the stomach for this sort of appropriation might be lacking.

“I really don’t see an appetite for it in the state legislature,” Davis said. “I think my colleagues will see that as a cost in addition to something that is already costing money.”

Though related appropriations are still speculative, Rep. Greg Jamison, a Republican who was a vocal proponent of expanding Medicaid, is certain that the legislature will at the very least appropriate the $13 million requested by the governor.

“There are a lot of my Republican friends who are not happy with it, and they may think that they could stop it or defund it or something, but they’ll realize that that’s not possible,” Jamison said. “The governor seemed a little bit begrudging but she played it pretty safe and did say it’s the will of the voters, so she definitely understands that.”

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Opinion | What Comes Next for the War on Drugs? The Beginning of the End

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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]: 2 key pieces of legislation (1 of them Medicaid-specific) are on the table to impact access to life saving substance abuse treatment medications.

 
 

Clipped from: https://www.nytimes.com/2022/12/12/opinion/drug-crisis-addiction.html

 
 

By The Editorial Board

The editorial board is a group of opinion journalists whose views are informed by expertise, research, debate and certain longstanding
values. It is separate from the newsroom.

There are three bills floating through Congress right now that could not only save lives and money but also help to finally dismantle the nation’s failed war on drugs. The Medicaid Re-entry Act, the EQUAL (Eliminating a Quantifiably Unjust Application of the Law) Act and the MAT (Mainstreaming Addiction Treatment) Act all have bipartisan support and could be passed during the lame duck session of Congress. Lawmakers should act on them without delay.

The MAT Act would eliminate the special Drug Enforcement Administration waiver that doctors must apply for in order to prescribe buprenorphine (a medication that helps reduce the craving for opioids). It would enable community health aides to dispense this medication as long as it’s prescribed by a doctor through telemedicine. And it would give the Substance Abuse and Mental Health Services Administration responsibility to start a national campaign to educate health care practitioners about medications for opioid use disorder. Reams of data have shown and addiction specialists agree that these medications offer some of the best options for preventing overdoses and helping people into recovery. But a 2019 report from the National Academies of Sciences, Engineering and Medicine found that fewer than 20 percent of people who could benefit have access to them.

There are several reasons for that, including stigma and a lack of understanding about how medications for opioid use disorder work. The biggest problem is that so few doctors are willing to treat addiction in the first place. Dropping the D.E.A. waiver will not be enough to alleviate that shortage; lawmakers will also have to find ways to ensure that addiction treatment enjoys the same robust reimbursement rates as other chronic conditions. But eliminating the waiver would still be a crucial step in the right direction. The prescription drugs that caused the current epidemic should not be easier to access than the medications that could help alleviate it.

The MAT Act, which was written by Representative Paul Tonko of New York, boasts some 248 co-sponsors and has already passed the House as part of a broader mental health package.

 
 

The Medicaid Re-entry Act would allow states to reactivate Medicaid for inmates up to one month before their scheduled release from prison. Those benefits are normally suspended (or in some states terminated) during incarceration because current law prohibits jail and prison inmates from receiving federal health insurance. Reinstating them after incarceration takes time and resources that people who have just been released from jail or prison don’t necessarily have. The resulting disruptions in medical care can be dire: America’s prison population suffers disproportionately from a range of serious ailments, including mental illness, heart disease and opioid use disorder. Among other risks, former prisoners are 50 to 150 times as likely to die of an overdose in the first two weeks after their release.

Closing the post-incarceration treatment gap would go a long way toward reducing such deaths. The Rhode Island Department of Corrections reduced its post-incarceration overdose fatalities by 60 percent by ensuring that inmates could access methadone and buprenorphine both during incarceration and after release, without disruption. “It was basically a slam dunk,” says Keith Humphreys, an addiction expert at Stanford University and a former senior adviser to President Barack Obama on drug policy. “Instead of sending them off with a brochure, you connect them to treatment.”

 
 

Reinstating Medicaid before release would be another, even more robust way to accomplish the same goal. Several states have already applied for federal waivers that would allow them to do so on a trial basis. The Biden administration should approve those waivers without delay. But Congress should also pass the Medicaid Re-entry Act so that the benefit of seamless care isn’t determined by where an inmate is incarcerated.

The bill, which was also written by Mr. Tonko, has bipartisan backing in both chambers and support from a wide range of groups, including the National Alliance on Mental Illness and the National Sheriffs Association. Experts on addiction believe it could save both lives and money. “It would open up a world of possibilities for taking care of people who are newly released,” Mr. Humphreys says. “There is really no reason not to do it.”

The EQUAL Act would eliminate the federal sentencing disparity between drug offenses involving crack cocaine and powder cocaine. That disparity was created by a 1986 law that equated 50 grams of crack with 5,000 grams of powder cocaine and subjected possession of either to a minimum sentence of 10 years in prison.

Editors’ Picks

 
 

The law was based on the now disproved idea that crack cocaine is far more addictive than powder cocaine. It resulted in disproportionately harsher penalties and far more prison time for drug offenders in communities of color: While two-thirds of people who smoke crack are white, 80 percent of people who have been convicted of crack offenses are Black.

In 2010, Congress reduced the crack-to-powder ratio from 100:1 to 18:1. The EQUAL Act would finally eliminate it altogether. If passed, approximately 7,600 people who are serving excessive crack-related sentences could be released an average of six years earlier, according to an estimate from the U.S. Sentencing Commission. That comes out to some 46,500 fewer prison years.

EQUAL, which was written by Representative Hakeem Jeffries of New York, who was recently elected leader of the House Democrats, passed the House last year with overwhelming bipartisan support. We urge the Senate to pass it. Lawmakers should get this long overdue bill across the finish line now, before House investigations and other political battles take priority in the next session.

The nation’s five-decade war on drugs has been a dismal failure. Overdose deaths have reached — and then surpassed — extreme levels in recent years, and the number of people who are still in prison for drug offenses remains stubbornly and egregiously high. Still, it is hard to agree on what comes next. What has been shown to work is not always politically feasible, and what’s politically popular often doesn’t make for sound public health. The MAT, EQUAL and Medicaid Re-entry Acts meet both requirements. Congress should pass all three now.

 
 

 
 

 
 

 
 

 
 

 
 

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OR- Kotek names interim director for the Oregon Health Authority

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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]: Welcome to Oregon’s new Medicaid Director!

 
 

Clipped from: https://oregoncapitalchronicle.com/2022/12/13/kotek-names-interim-director-for-the-oregon-health-authority/

James Schroeder, CEO of Health Share of Oregon, has 20 years of clinical and executive health care experience


James Schroeder, CEO of Health Share of Oregon, the state’s largest Medicaid insurer, will become the interim director of the Oregon Health Authority on Jan. 10. (Courtesy of Gov.-elect Tina Kotek’s office)

Gov.-elect Tina Kotek will appoint a 20-year health care veteran to lead the Oregon Health Authority in early January, at least temporarily.

In a statement on Tuesday, she said that James Schroeder, currently the CEO of the state’s largest Medicaid insurer, Health Share of Oregon, will serve as interim director.

“James brings over 20 years of management, leadership and health care delivery experience and a deep respect for the work of the OHA,” Kotek said. “Addressing the cracks in our mental health and addiction services systems will be a top priority for my administration, and I am confident that James has the experience and determination to get results for Oregonians.”

Schroeder will start Jan. 10, the day after Kotek takes office. He will replace Patrick Allen, who announced last month that he will step down Jan. 9. Steve Allen, the health authority’s behavioral health director, will leave the same day. Kotek said during her campaign she would replace both Allens, who are not related.

Patrick Allen brought to the agency years of government leadership experience, including as director of the Department of Consumer and Business Services, which oversees most insurance companies. Schroeder has clinical and administrative health care experience. He was trained as a physician’s assistant, a role that includes prescribing medications, and has worked in clinical and managerial roles. 

For the past two years, he’s led Health Share, which insures 426,000 Medicaid patients in the Portland area. Before that he held several top positions at Kaiser Permanente, including as vice president of safety net transformation and medical director of Medicaid. And since 2013, he’s served as medical officer in the Oregon Air National Guard, according to his LinkedIn page.

Schroeder also has worked as a clinician and executive in medical clinics that serve many Medicaid patients, founding and serving as CEO of the Neighborhood Health Center in the Portland area.

A leading Portland advocate, Kevin Fitts, executive director at Oregon Mental Health Consumers Association, welcomed Schroeder’s medical background. Fitts said his experience working with patients and ethical training to “do no harm” will be crucial for the state’s work in Medicaid and behavioral health.

Andrea Cooper, Kotek’s chief of staff, told health authority employees in an email on Tuesday that they will likely see Schroeder in the office before he assumes the interim role, working with Allen on the transition. She urged them to support him in the new role.

Multi-billion dollar budget

The health authority is one of the biggest agencies in Oregon in terms of budget – more than $17 billion a year in the current budget cycle – and it has 4,770 employees. The agency is responsible for most of the state’s health care programs, including behavioral health, public health and Medicaid, which covers one in three Oregonians.

When the federal health care emergency ends, which could happen in mid-January, the agency will need to audit the 1.4 million Oregonians covered by Medicaid to weed out those who no longer qualify because they make too much money. The agency also needs to bolster the state’s mental health services. For years, Oregon has ranked in national surveys as having the highest or among the highest share of people suffering with mental health and addiction problems and a lack of treatment options.

The Legislature has allocated $1 billion to create behavioral health and addiction treatment and social service networks, but Fitts said the behavioral health system continues to languish. He said the next director will need to ask tough questions and look for solutions that go beyond the system as it is now, he said.

Schroeder acknowledged that challenge in a statement.

“Our state is at a critical turning point, especially when it comes to the delivery of mental health and addiction services. I am honored by this appointment, and I want Oregonians across the state to know that I take this responsibility very seriously,” Schroeder said in a statement. “I will work tirelessly to ensure that the OHA team produces results for our communities.”

Focus on equity

Allen said he’s worked closely with Schroeder for years, saying he’s well qualified. The two have been in contact more frequently in recent weeks as it became clear that Schroeder would succeed him, at least on an interim basis. 

Besides working on behavioral health issues and homelessness, two of Kotek’s priorities, Schroeder will face a big challenge trying to make health care more equitable, Allen said. He set an agency goal of achieving equity by 2030. Allen said the agency’s culture has changed since he took the helm to emphasize equity. He said that needs to be a part of all of the agency’s programs for the state to advance.

“If you’ve got big chunks of the population that are disconnected from all of that and you don’t pay attention to health equity, you’re really not serving the need that you need to serve,” Allen said. “That’s a big cultural change that took a long time to begin to get to.”

Allen said keeping a focus on equity has been one of the most difficult parts of the job because the agency is frequently grappling with a crisis, such as a disease outbreak. For much of the past three years, it’s been focused on the pandemic. Allen said it’s human nature to focus on the immediate crisis but that can mean that health inequities continue to dog the state.

“For any director of OHA, that part is harder. And it’s often the part that gets left behind because because the rest of the problem is so urgent.” 

It’s not clear whether Kotek plans to appoint Schroeder to serve as the permanent director or will consider him. A spokeswoman, Katie Wertheimer, did not immediately respond to a request for comment about that.

Allen said that when he was appointed to lead the agency by Gov. Kate Brown in 2017 it was initially on an interim basis.

Fitts said he’s optimistic that Schroeder will be able to bring needed change to the health authority.

“The status quo is unacceptable,” Fitts said. “I think we need a visionary and we need somebody to have the courage to be above board and talk about these issues.”

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FWA (NY) Attorney General James Secures Over $3 Million from Home Health Agency for Cheating Workers and Medicaid Fraud

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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 NY home health agency pocketed the extra money it was supposed to give to workers. $2M of it.

 
 

Clipped from: https://ag.ny.gov/press-release/2022/attorney-general-james-secures-over-3-million-home-health-agency-cheating-workers

White Glove Community Care Fraudulently Obtained More Than $1 Million
in Medicaid Funds and Failed to Pay Required Wages to Employees

Company Agrees to Pay $1.2 Million to Medicaid Program
and
Return $2 Million to Current and Former Employees

NEW YORK – New York Attorney General Letitia James today announced two agreements with White Glove Community Care, Inc. (White Glove), a Brooklyn-based home health agency, for causing false claims to be submitted to Medicaid and cheating employees out of hard-earned wages. Under the agreements, one reached with the Office of the Attorney General’s (OAG) Labor Bureau and the other with OAG’s Medicaid Fraud Control Unit (MFCU), White Glove will return $2 million in unpaid wages to workers and pay $1.2 million to the New York State Medicaid Program (Medicaid). White Glove has admitted to wrongful conduct. The United States Attorney’s Office for the Eastern District of New York (EDNY) is also party to the settlement resolving White Glove’s Medicaid fraud liability.

“Home health aides work tirelessly to provide critical care for our most vulnerable neighbors, and they deserve to receive adequate and fair compensation for their hard work,” said Attorney General James. “White Glove cheated their employees, and they cheated the everyday New Yorkers whose tax dollars fund the Medicaid program. My office will always stand up against bad actors, and ensure all workers get fair pay for their work.”

“The arduous work that these aides do, day after day, ensures that some of our most vulnerable neighbors receive the care and are shown the dignity that they deserve,” said United States Attorney Peace. “This settlement — the third in our continuing investigation of certain licensed home care service agencies — reflects this Office’s ongoing commitment to providing home health aides the hard-earned benefits guaranteed them under New York law and the Medicaid program.”

The New York Wage Parity Act sets wage and benefit minimums that state-licensed home care services agencies (LHCSAs) are required to pay to employees who perform home health aide and personal care services to Medicaid recipients. Under the law, workers are entitled to a base wage of $17.00 per hour, paid by the agencies, in New York City, Nassau, Suffolk, and Westchester counties, or $15.20 per hour for the remainder of the state, and an additional fringe benefit of $4.09 per hour in New York City or $3.22 per hour in Nassau, Suffolk, and Westchester counties. The Medicaid program reimburses LHCSAs for the cost of services provided to Medicaid recipients, and reimbursement is conditional on the agency’s compliance with the requirements of the Wage Parity Act.

The joint investigation by OAG and EDNY found that White Glove failed to pay its home health aides and personal care aides the required wages and benefits owed to them pursuant to the Wage Parity Act; sought payment from Medicaid and received money for care performed by aides who were underpaid; and falsely certified compliance with the Wage Parity Act.

Between March 2012 and December 2018, White Glove underpaid its home care aides. As a result of the settlement announced today, White Glove will pay a total of $2 million to OAG for distribution to current and former employees.

White Glove will also revise company policies and procedures; train personnel on updated policies subject to OAG’s approval; and regularly report staff wages and policy implementations to OAG for a period of three years. If White Glove fails to comply with these terms or properly compensate its aides, OAG has the authority to bring a civil action against the agency and demand $15,000 in damages for violating its legal obligations.

White Glove will also pay more than $1.2 million to the Medicaid Program, of which $758,425.47 will go to New York state. The remaining $505,616.98 will be paid to the federal government.

The OAG and EDNY commenced these investigations after whistleblowers filed a complaint under the qui tam provisions of the New York False Claims Act and the federal False Claims Act in the United States District Court for the Eastern District of New York. The New York False Claims Act allows individuals to file actions on behalf of the government and share in any recovery. The state has since filed a notice of intervention against White Glove for the purposes of settling its Medicaid fraud claims.

Attorney General James thanks United States Attorney Peace and EDNY for their collaboration on this matter.

MFCU’s total funding for federal fiscal year (FY) 2023 is $65,717,936. Of that total, 75 percent, or $49,288,452, is awarded under a grant from the U.S. Department of Health and Human Services. The remaining 25 percent, totaling $16,429,484 for FY 2023, is funded by New York state. Through MFCU’s recoveries in law enforcement actions, it regularly returns more to the state than it receives in state funding.

This matter was handled for MFCU by Special Assistant Attorneys General Ting Ting Tam, Jill D. Brenner, and Hillary G. Chapman under the supervision of MFCU Civil Enforcement Division Chief Alee N. Scott. The cases were investigated by Principal Auditor Investigator Milan Shah and Auditor-Investigator Khristian Diaz under the supervision of Regional Chief Auditor Stacey Millis. MFCU is led by Director Amy Held and Assistant Deputy Attorney General Paul J. Mahoney. MFCU is a part of the Division for Criminal Justice, led by Chief Deputy Attorney General José Maldonado.

This matter was handled for the Labor Bureau by Assistant Attorneys General Anielka Sanchez Godinez and Kristen Ferguson with the assistance of Civil Enforcement Section Chief Fiona J. Kaye and Former Civil Enforcement Section Chief Ming-Qi Chu, under the supervision of former Deputy Bureau Chief Julie Ulmet and Bureau Chief Karen Cacace. Additional Assistance was provided by Data Scientist Chansoo Song and Deputy Director Megan Thorsfeldt of the Research and Analytics Department. The Labor Bureau is a part of the Division for Social Justice, which is led by Chief Deputy Attorney General Meghan Faux.

Both the Division for Criminal Justice and the Division for Social Justice are overseen by First Deputy Attorney General Jennifer Levy.

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FWA- Ohio Medicaid ripped off for millions, and counties could have stopped it, auditor says

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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]: States (and their counties) continue to not use the fraud fighting tools available to them.

 
 

 
 

Clipped from: https://www.13abc.com/2022/12/13/ohio-medicaid-ripped-off-millions-counties-could-have-stopped-it-auditor-says/

 
 

A report from the Ohio Auditor of State found that county offices are not reacting to alerts, that Medicaid recipients may be getting payments and benefits from multiple states.

CLEVELAND, Ohio (WOIO) –The Ohio Auditor of State released a report Tuesday looking into Ohio Medicaid recipients who have been getting payments and or benefits, from multiple states which is not allowed.

Auditor Keith Faber says counties, who sign up and review Medicaid recipients had been getting alerts from the federal level when people were identified as “double dippers.”

Alerts are sent to each county by a program called Public Assistance Reporting Information System (PARIS), a monitoring program aimed to catch people enrolled in multiple states.

Since following the alerts in July of 2022, the auditor’s office claims 59% of the alerts were not acted upon meaning several Ohio Medicaid recipients continued to get benefits from multiple states.

According to the report, failure to act cost Ohio and taxpayers somewhere between $5.3 million and $24.5 million annually.

“There continue to be ongoing oversight issues in Ohio’s Medicaid programs that should have been addressed,” Auditor Faber said. “It’s past time to deal with these problems.”

There are approximately 2.9 million Ohioans enrolled in Medicaid who are lower income residents, older adults, individuals with disabilities, pregnant women, infants and children, and others.

According to a news release from the auditor’s office, “Tuesday’s report follows a separate audit released in January 2022 that found the Ohio Department of Medicaid (ODM) failed to recoup more than $118.5 million in erroneous duplicate payments or improperly paid for the managed care of prison inmates and deceased residents over a three-year period.”

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FWA (CT) – Greenwich Psychologist Admits Defrauding Medicaid, Medicare and Private Insurers

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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]: You paid $2.6M for this guy in CT to bill Medicaid for services not rendered, including to dead patients, or patients who were in the hospital at the time and could not receive his services. Oh yeah- he got kicked out of Medicare 15 years ago for fraud, but Medicaid was happy to pay him.

 
 

Clipped from: https://www.justice.gov/usao-ct/pr/greenwich-psychologist-admits-defrauding-medicaid-medicare-and-private-insurers

Vanessa Roberts Avery, United States Attorney for the District of Connecticut, Phillip Coyne, Special Agent in Charge for the U.S. Department of Health and Human Services, Office of Inspector General, and David Sundberg, Special Agent in Charge of the New Haven Division of the Federal Bureau of Investigation, today announced that MICHAEL LONSKI, 71, of Greenwich, waived his right to be indicted and pleaded guilty yesterday before U.S. District Judge Sarala V. Nagala in Hartford to health care fraud.

According to court documents and statements made in court, Lonski is a licensed psychologist who, along with another licensed psychologist (“Individual 1”), has operated a practice out of his home office in Old Greenwich.  Lonski and Individual 1 were authorized providers for the Connecticut Medicaid program (“Medicaid”), Medicare and other health care benefit programs.  Lonski assumed responsibility for submitting claims for reimbursement for services allegedly provided by himself and by Individual 1, both at their home office and at various skilled nursing facilities within Connecticut.

In pleading guilty, Lonski admitted that he billed insurers for services that he knew were not rendered, including by billing for patients who were deceased, for dates of service when he was out of the country, for dates of service when Individual 1 was out of the country, and for dates of service when he was hospitalized.  These fraudulent claims resulted in a loss of over $2,651,296, including a loss of $1,157,292 to the Connecticut Medicaid program and a loss of $119,092 Medicare.

Health care fraud carries a maximum term of imprisonment of 10 years.  Judge Nagala scheduled sentencing for March 10.  As part of his plea, Lonski has agreed to pay full restitution.

Lonski is released on bond pending sentencing.

In 2002, Lonski settled a federal lawsuit alleging health care fraud offenses, which was brought by the government in the Southern District of New York.  Lonski agreed to pay $4 million in restitution and was excluded from participating in the Medicare program from April 2003 to November 2007.  He was reinstated to the Medicare program in approximately December 2008.

This investigation has been conducted by the U.S. Department of Health and Human Services, Office of the Inspector General (HHS-OIG), and the Federal Bureau of Investigation. The case is being prosecuted by Assistant U.S. Attorney Susan L. Wines.

People who suspect health care fraud are encouraged to report it by calling 1-800-HHS-TIPS.

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FWA (IL) – Owner Of Beverly Medical Center Charged In $224K Medicaid Scam

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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]: You paid $224k for bogus Medicaid claims to a mental health clinic in Illinois.

 
 

Clipped from: https://patch.com/illinois/beverly-mtgreenwood/owner-beverly-medical-center-charged-224k-medicaid-scam-raoul

Crime & Safety


Easter Jean Watson faces theft, fraud and forgery charges after officials said she submitted claims for psychotherapy services not provided.

 
 

Jeff Arnold,

Patch Staff

 
 

Posted Wed, Dec 14, 2022 at 12:05 pm CT

 
 

The owner of a Beverly-based mental health clinic fraudulently submitted Medicaid claims for psychotherapy services she never provided, according to criminal charges brought by the state’s Attorney General. (Shutterstock)

CHICAGO — A 74-year-old Chicago woman and owner of a Beverly-based mental health clinic faces criminal charges after prosecutors said that she filed nearly $225,000 in false Medicaid claims, officials announced on Wednesday.

Easter Jean Watson has been charged with theft, fraud and forgery and could spend the rest of the rest of her life in prison if convicted, Illinois Attorney General Attorney Kwame Raoul announced. Watson is charged with managed health care fraud, two counts of theft and forgery in connection with the alleged fraudulent activity.

Watson is a licensed clinical social worker and the owner of Loudek Community Services, according to a news release. Raoul said in a news release that she submitted claims for psychotherapy and counseling services that she did not provide to 10 Medicaid Managed Care patients.

Find out what’s happening in Beverly-MtGreenwoodwith free, real-time updates from Patch.

A message left at the health clinic seeking comment on the charges brought against Watson was not immediately returned to Patch on Wednesday.

According to the agency’s website, the organization provides a Behavioral Health Agency whose overall goal is to provide quality, comprehensive, holistic services to individuals across the lifespan. Loudek, the website said, is dedicated to improving the quality of life of those individuals we serve through psychotherapeutic counseling, advocacy, crisis intervention, family stabilization and substance abuse treatment.

Find out what’s happening in Beverly-MtGreenwoodwith free, real-time updates from Patch.

“Thousands of Illinois residents rely on Medicaid for their health care. It is unconscionable that a health care provider would defraud the people of Illinois by allegedly misusing needed Medicaid resources,” Raoul said. “I am committed to working with the Illinois State Police to identify Medicaid fraud and hold those who engage in it accountable.”

The case was investigated by the Illinois State Police Medicaid Fraud Control Unit, Raoul said.

“The Illinois State Police will continue to work closely with Attorney General Raoul’s office to ensure those who attempt to defraud government and the taxpayers will be brought to justice,” Illinois State Police Director Brendan Kelly said in a news release.

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FWA (NC) – Attorney General Josh Stein Announces Medicaid Fraud Pleading

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]: You paid $32k for a Medicaid transportation scam.

 
 

Clipped from: https://ncdoj.gov/attorney-general-josh-stein-announces-medicaid-fraud-pleading/

 
 

For Immediate Release:
Friday, December 9, 2022

Contact: Nazneen Ahmed
919-716-0060

(RALEIGH) Attorney General Josh Stein today announced that Terry Lee Sayre has pleaded guilty to the felony of obtaining property by false pretenses in Brunswick County Superior Court. Judge Jason C. Disbrow sentenced Sayre to 60 months of supervised probation. Sayre also was ordered to pay $ 31,882.50 in restitution to the North Carolina Medicaid Program.

“When people cheat the Medicaid program, they’re cheating North Carolina’s taxpayers,” said Attorney General Josh Stein. “My office will not allow it. I commend District Attorney Jon David and my team for their hard work and partnership on this case.”

Medicaid pays for transportation to medical appointments for eligible recipients who need assistance with transportation. Sayre and his co-defendant, Julie Ridgdill, submitted fraudulent transportation invoices and forms to the Brunswick County Department of Social Services (Brunswick DSS). As a result, Brunswick County paid the defendants $31,882.50 of Medicaid funds for transportation services that were not provided. Ridgdill previously pleaded guilty and was sentenced to 6-17 months in jail, which was suspended, and she was placed on supervised probation for 24 months and ordered to pay restitution.

This case originated from a referral from the Brunswick County Sheriff’s Office. This conviction was obtained in collaboration with District Attorney Jon David.

About the Medicaid Investigations Division (MID)

The Attorney General’s MID investigates fraud and abuse by health care companies and providers, as well as patient abuse and neglect in facilities that are funded by Medicaid. Medicaid is a joint federal-state program that helps provide medical care for people with limited income. To date, the MID has recovered more than $1 Billion in restitution and penalties for North Carolina.

MID receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $6,106,236 for Federal fiscal year (FY) 2022. The remaining 25 percent, totaling $2,035,412 for FY 2022, is funded by the State of North Carolina. To report Medicaid fraud in North Carolina, call the North Carolina Medicaid Investigations Division at 919-881-2320. 

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MCO News- Nonprofit Health Plans With $6.8 Billion in Projected Revenue Set to Combine

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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]: SCAN has a new way to enter a new MCO market with its new arrangement with CareOregon.

 
 

Clipped from: https://sdbig.com/nonprofit-health-plans-with-6-8-billion-in-projected-revenue-set-to-combine/

 
 

 

 
 

We are thrilled to announce that SCAN and CareOregon intend to come together as the HealthRight Group.

 
 

We believe that non-profit healthcare should be a bulwark of the healthcare system of the future.

 
 

Our two organizations will come together as a mission-driven organization to serve over 800,000 members in the Medicare and Medicaid programs in Arizona, California, Nevada, Oregon; and Texas.

 
 

I am thrilled to partner with Eric C. Hunter and grateful to the boards of our respective organizations for their vision and imagination in supporting this combination.

 
 

From <https://www.linkedin.com/feed/update/urn:li:activity:7008850887691436032/>

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NY- Medicaid reimbursements inadequate to cover new $17 minimum for home health aides, agencies say

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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]: Home health workers say they are not seeing the money appropriated to up their wages; MCOs say not everybody was supposed to get a raise per the legislation; the legislator who sponsored the bill that funded the increase said it was written poorly; home health agencies cry Big Bad MCOs; and Big Union blames everybody.

 
 

Clipped from: https://www.newsday.com/business/home-health-aide-medicaid-minimum-wage-mkef5db1

Home care worker Mildred Garcia-Gallery, right, assists Christine Cipriani at Cipriani’s home in Garden City South. Credit: Newsday/J. Conrad Williams Jr.

An hourly wage increase of $2 designed to help ease the shortage of home care aides is finally in place, but industry players disagree about whether the raise can accomplish its goal without collateral damage. 

At stake is home care for Long Island’s growing older population. The region has around 40,140 home care and personal care aides, and is projected to see openings increase by over 64% by 2028,  according to the state Department of Labor. Agencies that employ home health aides have said they had trouble attracting workers for the demanding jobs at the previous $15 an hour minimum wage in a market where workers can often make more at Target or Walmart.

In the years prior to the state’s multi-year push to a $15 overall minimum, agency advocates said aides were regularly offered starting pay above minimum wage. But as the minimum wage increased,  state-assigned Medicaid reimbursements for many home care agencies did not keep pace,  leaving them  struggling to keep up.

 Home care agencies hailed the move to $17 an hour as a victory when lawmakers included it in the state budget this spring, allocating $7.7 billion to fund it over the next four years. 

But now, with the increase in effect since Oct. 1, some agencies say they’re not being reimbursed enough to cover the higher pay. They blame the insurance companies that administer the state Medicaid funds. And they say the raise could end up having the opposite effect, forcing them to reduce workers’ hours and cut staff, or even putting their businesses at risk.  

On the other side, the insurance companies charge that some agency owners, already receiving adequate reimbursements, are asking for more just to pad their profits.

A workers’ union says both things are happening. And a legislator who pushed for the higher wage blames poorly crafted language in the state budget for the mess that has threatened the goal — to address the labor shortage and make more caregivers available. 

“It is critical that the funds that legislators intended to go to worker pay do exactly that,” said Kathy Febraio, president and chief executive of the New York State Association of Health Care Providers, a trade group representing around 125 home care agencies. 

According to an Oct. 5 survey of Febraio’s membership, 75% said they were not getting reimbursement rates high enough to cover increased payroll costs. If the rates they’ve been offered weren’t raised, 29% of respondents said they would reduce staffing levels, with 72% saying they would reduce service hours.

Twelve percent of respondents said they would go out of business.

Representatives for insurance plans, though, reject the assertion that they are withholding reimbursement dollars or providing inadequate reimbursement to agencies.

 Insurance plans “have been working diligently to allocate the wage funding provided to them to home care providers which in turn should be spent on workers,” said Eric Linzer, president and chief executive of the New York Health Plan Association, a trade group representing the managed long-term care insurance plans that administer the funds.

“No health plan is paying any provider less than what they need to meet wage, benefit and administrative requirements,” Linzer said. “What’s happening here is you have some providers that already have received enough funding. It kind of begs the question of why do some of them need more, other than to pad profits.” 

“I’m very happy that [workers are] getting the increase,” said Nicole Laborde, who owns Ideal Home Care Services in Hauppauge, a provider of home health aides. “However, it’s going to affect a lot of home health care agencies, especially smaller ones.”

Laborde said the insurance providers aren’t providing high enough reimbursement rates to agencies.

“Nobody really looked at how the home care agencies are going to be compensated to be able to afford this increase,” said Laborde, who is also founder and chief executive of Ideal School of Allied Health Care in Hauppauge, which trains health care workers including home aides.

The wage increase is meant to help address a critical labor shortage that’s only expected to worsen as the need for home care aides grows in the coming years.

Aging Baby Boomers have increased the demand for home health services on Long Island as the preference for “aging in place” has grown, said economist Shital Patel with the Labor Department’s Hicksville office. Health care reform has also encouraged the use of home care as an alternative to expensive nursing homes and hospital stays, she said.

There are more than 1,300 licensed or certified home care agencies statewide, according to the New York State Association of Health Care Providers. 

Competition for entry level workers from employers like Amazon and Target offering higher hourly wages in the wake of the pandemic has only exacerbated the difficulty in recruiting aides,  who provide critical services to seniors and others living at home. Aides not only provide care, but can often become a vital source of companionship,  developing close relationships with patients and their families, said aides and care recipients. 

Because most patients use Medicaid to cover home care, wages for workers largely rely on reimbursement rates set by managed long-term care plans. While Medicaid is traditionally government health insurance for the most impoverished Americans, it is one of the few ways patients can cover the high cost of home care.

“There are only a few ways to pay for home care,” said Nicole Christensen, patient advocate and president of Care Answered, a Freeport business that helps families navigate the complex world of health care for seniors. Because private health insurance seldom covers home care, she said patients have three options when paying for those services: Paying out of pocket “which becomes very expensive very quickly;” long term care insurance, “which not many people have,” and community-based Medicaid, a form of Medicaid that specifically covers nursing home-level care in the home.

 Agencies said they would like to see the state Health Department step in and set a standard reimbursement rate  for agencies, which currently negotiate  individually with insurance firms.

On average, Febraio said members of her trade organization have been receiving $1.33 per hour in extra reimbursement, half of the $2.66 the group estimated members would need to cover wage increases plus higher payroll taxes and other related costs. 

“I believe the Department of Health thought the money would flow through the plans to providers and ultimately to the workers,” Febraio said. “The information that we’re giving to them is making it clear that that’s not happening.”

Linzer, representing the insurance firms, said that when the state set aside funding for reimbursement , they did not intend for every agency to receive a bump of $2 if their existing contracts had higher rates to begin with.

“The state has been very clear that this is not supposed to be a directed payment where everyone gets a $2 increase,” he said. “In instances where you have contracts that exceed the new wage requirements, there will be less of an increase.” 

The median annual wage for home health and personal care aides is $31,893 on Long Island, according to state labor data, with experienced aides earning an average of $18.46 an hour.

Sen. Rachel May (D-Syracuse), sponsor of the original fair pay for home care workers legislation that failed to pass but instead was adopted in part in the governor’s budget, said the intent of increasing home care workers’ wages was to retain workers and grow the industry. Now, she said she’s concerned that if agencies aren’t given high enough rates, the wage increases run the risk of making a bad situation worse.

“The fact that the bill didn’t pass and got folded into the budget means a bunch of language we put in the bill to avoid this exact situation didn’t end up in law,” May said. “It’s the opposite of what we’re trying to accomplish here.”

The governor’s office said that due to financial measurements introduced through the Affordable Care Act, insurers handling Medicaid reimbursement cannot keep the money  passed through them.  Additionally, the state is encouraging home health agencies to report insufficient payments for wage increases to the Health Department.

The department will also “keep reiterating” its guidance on the matter with insurers to ensure compliance, the governor’s office said. 

May said she is now working to ensure that taxpayer dollars go to adequately funding agencies so they can pay their employees more. A major structural hurdle is that the reimbursement rates negotiated between insurance companies and agencies are not disclosed to the state, making it more difficult to determine whether insurance plans are paying high enough rates, she said.

“The biggest struggle we have is transparency,” May said. “We don’t know what the terms are of a lot of the contracts.”

Mildred Garcia-Gallery, 53, a consultant, home health aide and activist, said she worked with the New York Caring Majority — a coalition of aides, agencies and elected officials —aides to campaign for higher wages in the industry and reimbursement rates to support them.

After hearing about the state’s plans to adopt a higher wage early this year, she was ecstatic. Now, she said she worries whether higher costs for agencies will mean fewer hours for workers.

“It felt like a slap in the face,” said Garcia-Gallery, who’s worked in home care for 30 years and consults with agencies through her firm Ageless Companions LLC.

She said if agencies are forced to cut hours for workers, then aides won’t be able to earn the overtime pay they need to make ends meet, resulting in picking up work with additional agencies to get by. 

“I could find another job but what about these patients? If we exit, what happens?” she said. “It’s a job that I love. But loving it and surviving off of it are two separate things.”

Officials representing unionized aides said they have heard of plans paying rates too low to cover the increased costs, but also said some agencies are more concerned about profit than the wages of their workforce.

“We don’t always agree with the employers and we sometimes think they keep too much of the funding themselves,” said Helen Schaub, political director for 1199SEIU, the union representing 53,000 home care workers in the state, including 5,000 on Long Island. “You have to look agency by agency.”

Schaub said while the wage increase is good for workers, the ultimate problem is that for-profit insurance firms are involved in the Medicaid reimbursement process at all, instead of rates being negotiated directly with the state.

“What has been happening is that the state puts in money at the top and there’s this finger pointing between the employer and plans about who is keeping the money,” she said. 

 The $17 minimum applies to   home health workers on Long Island, in Westchester and in New York City. In other parts of the state, where the minimum for most workers is $13.20, the minimum for aides has gone up to $15.20. Home care workers across the state are scheduled to receive another $1 increase next October.

Winsome Gayle Allen, 58, said the sometimes-challenging work of caring for patients at home has been a personal calling for 40 years.

“The type of work where I feel comfortable is giving my time to elderly people,” said Gayle Allen, of Hollis, Queens, an aide with Fresh Meadows-based Reliance Senior Living Services.

Gayle Allen, who’s been serving patients in New York since moving to the states from Jamaica with her parents at 19, said she’s developed long-lasting relationships with patients and their families.

While she loves what she does, she admits the work can be difficult at times and requires a lot of empathy and patience. Given the demanding hours and low wages, she said workers are in dire need of pay increases above what’s currently being offered.  

“I’m not going to beat around the bush…I think we should get a starting pay of $20 an hour,” she said.

Christine Cipriani, 91, of South Garden City said she doesn’t know what she’d do if she didn’t have the support of her regular home care aide Mildred Garcia-Gallery.

“It’s vital for me,” Cipriani said. “My kids are very nice kids, but they have their own stuff to worry about.”

Cipriani said Garcia-Gallery first came into her life three years ago when the aide was looking after her husband until he died a year ago. “She’s like part of my family,” she said.

For Garcia-Gallery, helping Cipriani and other patients fills her with a sense of purpose and comes with emotional rewards.

“I like being needed and having that responsibility,” she said. “We like to do this job because we like to care for people, we love people and we love making people’s lives better or at least trying to.”

Still, she said, while the work “makes me feel important, it doesn’t mean my pay reflects that.”

For Thomas McCarthy, 24, a wheelchair user living in Farmingdale, having access to reliable home care gives him the opportunity to be more independent, he said.

“With just me and my aide helping me out, I’m not so dependent,” said McCarthy, who has Duchenne muscular dystrophy, a condition that progressively weakens muscles over time.

His aide, Marc Bazile, 52 — who lives in McCarthy’s family home every other week to provide round-the-clock care — said the work he does helping others makes him feel good and helps him appreciate the independence he has in his own life.

“I love family. I love to help people,” said Bazile, an aide with Ideal Home Care Services, who commutes from Lancaster, Pennsylvania every other week to assist McCarthy.

Still, Bazile said, pay remains an issue. As an experienced aide already making more than minimum wage, he said he hasn’t seen any impact from the recent $2-an-hour pay increase. 

— with Coralie Saint-Louis