Tag: State News

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OR- New Cancer Drug Access at Risk in Oregon Medicaid Proposal

[MM Curator Summary]: You can have faster cancer drugs or cost management. Not both.

 
 

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.

 
 

 
 

 
 

An Oregon proposal to exclude expensive drugs that received FDA fast-track approval from Medicaid coverage is alarming advocates for patients with cancer and other life-threatening diseases.

If approved, the proposal could limit access in Medicaid to promising treatments for patients with deadly conditions, and could encourage other states to similarly attempt to restrict access to get relief from rising drug costs, advocates say.

At issue are drugs approved under the Food and Drug Administration’s accelerated approval pathway, which emerged in the 1990s during the AIDS crisis as a way of speeding access to medications for patients with serious conditions and few, if any, treatment options. The pathway has gained renewed attention from lawmakers after the FDA approved Biogen Inc.’s Alzheimer’s drug Aduhelm against the recommendation of its scientific advisers.

Accelerated approval drugs can be very expensive—many of them over $10,000 per month—and many more are in the pipeline, according to Matt Salo, executive director of the National Association of Medicaid Directors. The Oregon proposal is a sign that states are worried about how they’ll pay for such treatments, he said.

Other states will be watching the response of the Centers for Medicare & Medicaid Services to the Oregon proposal “very closely,” Salo said.

Annual Medicaid spending on accelerated approval drugs increased from $728 million in 2015 to $1.44 billion in 2020, and the percentage of program spending that went to such drugs increased from 2.3% to 4.2%, according to a 2021 study in Health Affairs.

Confirmatory Trials

Drugmakers ordinarily must show that their products produce a benefit through lengthy and costly clinical trials to win approval—meaning a favorable effect on how a patient feels, functions, or survives.

Accelerated approval removes the requirement to run clinical trials upfront. Instead, drugs are approved based on their effect on a “surrogate endpoint,” an objective indication thought likely to lead to a clinical benefit.

The result has been quicker approval of promising drugs. But Oregon’s proposal zeroes in on a frequent criticism of the accelerated approval pathway: that it removes pressure on drugmakers to run the clinical trials that are needed to show that their products do, in fact, produce a clinical benefit.

The Oregon proposal is part of the state’s application to renew and amend its Section 1115 waiver, referring to special conditions under which it runs its Medicaid program.

Section 1115 is a part of the Social Security Act that deals with Medicaid and allows the secretary of the Department of Health and Human Services to waive program requirements to allow states to test new approaches to coverage and payment.

Oregon’s current waiver is set to expire June 30. The federal comment period on the renewal proposal closed April 7.

Current Medicaid regulations generally require states to cover all drugs that have been approved by the FDA, including where the drugmaker subsequently fails to show clinical efficacy within the timelines that were imposed as a condition of accelerated approval, the Oregon renewal application said.

In return for guaranteed Medicaid coverage for their FDA-approved drugs, drugmakers are required to pay large rebates to the states. Medicaid spent about $64 billion on outpatient prescription drugs in 2017, and collected $34.9 billion in rebates, resulting in net spending of $29.1 billion, according to the Medicaid and CHIP Payment and Access Commission.

Allowing Oregon to exclude accelerated approval drugs would give drugmakers an additional incentive to complete the required clinical trials, and would ensure that states are paying only for drugs that have been proven to provide a clinical benefit, Oregon said.

That is not always the case under the current system, said Rachel Sachs, a professor at the Washington University School of Law.

“There are cases where a drug manufacturer completes the confirmatory trial on a drug that has received accelerated approval, the trial fails, and the drug stays on the market,” Sachs said. “And the FDA either can’t or won’t remove it. And that raises an important question: should the states and the taxpayers have to spend their limited resources on a product that has no demonstrated evidence of clinical benefit?”

Cancer Drugs

But those who look at the issue of accelerated approval drugs from the standpoint of patients rather than of the Medicaid program as a whole ask a different question: whether it makes sense to allow states to restrict access to lifesaving drugs for low-income patients in the name of cost savings.

“This is a matter of incredible importance for cancer patients,” said Mark Fleury, a principal on the policy development team at the American Cancer Society. “Oncology makes up the lion’s share of accelerated approvals for all drug types, and within oncology, the majority of new molecular entities that have been approved over the past three years have been via accelerated approval.”

The impact on drug availability for patients who have no other treatment options have been dramatic, he said. The accelerated approval process has reduced the time for drugs to hit the market by 3.4 years on average.

“For cancer patients, that can make all the difference,” he said. “This process really is working. It really is granting patients earlier access to life-extending and lifesaving treatments.”

Policy Proposals

The problem with the Oregon proposal is that its target is the drug companies but its victims are Medicaid enrollees in need of accelerated approval drugs, said Wayne Turner, a senior attorney in the National Health Law Program.

“This isn’t a problem for the individual states to handle through the Section 1115 waiver program,” Turner said. “This is a matter for Congress.”

A variety of policy proposals have surfaced in Congress aimed at reforming the accelerated approval pathway and pressuring drug companies to complete confirmatory clinical trials.

These include allowing the FDA to take quicker action to remove drugs from the market once they have failed to demonstrate clinical benefit, requiring drugmakers to provide a plan for confirmatory trials before obtaining accelerated approval, increasing reporting requirements related to confirmatory trials, and imposing fines on drugmakers that fail to complete the trials.

A proposal floated by MACPAC would require drugmakers to pay increased rebates for accelerated approval drugs.

But looming in the background is a more fundamental issue for Congress to address, said Salo: how to help state Medicaid programs pay for an expected flood of expensive new treatments in the coming years.

“There’s a whole world of new therapies coming our way, we’ve really made it a national priority to go ‘all in’ on innovation, but we haven’t had the follow on conversation about the cost of innovation, and how we’ll pay for it,” he said.

“You’d find a lot of agreement from the states about this: we’re probably going to need help from our federal partners to spread the cost out more broadly.”

 
 

Clipped from: https://news.bloomberglaw.com/health-law-and-business/new-cancer-drug-access-at-risk-in-oregon-medicaid-proposal

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OK- Proposed Medicaid solution in legislation aims to improve efficiency and outcomes

[MM Curator Summary]: The state is now going with a provider-led entity model to bring managed care back (maybe).

 
 

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.

 
 

 
 

Measures to create a system for managing Oklahoma’s Medicaid program in-state authored by Rep. Marcus McEntire, R-Duncan, and Sen. Greg McCortney, R-Ada, are headed for discussion in conference committee. (Photo by Alexandr Podvalny via Unsplash)

OKLAHOMA CITY – After the courts put an end to Gov. Kevin Stitt’s plan to privatize much of the state’s Medicaid program last year, it was left to lawmakers to come up with an alternative solution – one that would improve efficiencies and outcomes while keeping administrative dollars in-state.

Rep. Marcus McEntire, R-Duncan, and Sen. Greg McCortney, R-Ada, are authors on legislation intended to do that. The measures have some additional hurdles to clear before they can be implemented, however, and are sure to be intensely “cussed and discussed,” as McEntire put it, during the last few weeks of the legislative session.

McEntire recently told lawmakers on the floor of the House of Representatives claimed the plan lawmakers are working on could reverse the trend of the last few years and help rural hospitals reopen, or resume providing obstetrics care.

“Every hospital, rural or urban, will be profitable again on their Medicaid clientele since the first time since the ACA (Affordable Care Act) was passed,” McEntire told lawmakers when the bills came before the full House of Representatives on April 28. “And we’re talking real money here, that they’re going to be able to reinvest in their communities.”

The plan gives lawmakers more control to continually tweak the program to address constituent needs, and to ensure that the healthcare companies involved are focused on efficiently spending Medicaid dollars to get the best health outcomes for patients.

After voters approved State Question 802 in 2020, expanding Medicaid, lawmakers set about figuring out a way to pay for it and make sure the program was administered efficiently. Stitt pushed for managed care, having the Oklahoma Health Care Authority award roughly $6 billion in contracts to a handful of national insurance companies.

The Oklahoma Supreme Court struck down that deal, finding OHCA did not have the legislative approval to move forward with the managed care plan, and the expansion approved by voters did not authorize such a program.

Oklahoma last attempted managed care in the 1990s, but amended the plan after seeing a precipitous decline in participating physicians, resulting in scarcity of care.

Oklahoma-based companies would better implement the state’s Medicaid program, and lawmakers should monitor progress to ensure that the funding they receive is concentrated in providing healthcare services rather than boosting profits, McEntire said. The proposed plan would encourage provider-led entities such as Integris to expand their accountable care organizations statewide, and those Oklahoma-based organizations would likely partner with larger, national companies to provide financial backing, he said.

“This plan puts an Oklahoma provider-led entity in the middle of that,” McEntire said. “The money will stop there in state. There is no doubt these provider led entities do not have the financial reserves to take on this much risk; they will need somebody financially backing them…

“If they overshoot those capitated amounts they’re going to need an insurance company behind them with the financial reserves to come in and bail them out because the state is not going to,” McEntire said.

The plan shifts the Medicaid program from a fee-for-service model to a value-based system, providing bonuses for improved outcomes and encouraging providers to take a more holistic approach to care.

Plus, the state would be able to leverage federal dollars to make sweeping change while keeping the cost of the program “net revenue neutral” for the state, McEntire said.

The measures were introduced as amendments on the House floor, introducing a lot of new language late in the legislative process. Though the measures were approved with overwhelming support in the House, the amendments were rejected by the Senate on May 5, sending the bills into discussions in conference committees over the next few weeks.

 
 

Clipped from: https://journalrecord.com/2022/05/09/proposed-medicaid-solution-in-legislation-aims-to-improve-efficiency-and-outcomes/

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Legislature delays negotiations of $4 billion Kansas Medicaid contracts until 2023

[MM Curator Summary]: The bill to handle MCO contract schedules directly by legislative power has moved forward in Kansas, but will be 1 vote shy of being veto proof from the Governor it is seeking to control.

 
 

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.

 
 

Bill also restricts governor’s authority to close churches during emergency

 
 

Rep. Brenda Landwehr, second from the left, and Rep. Kathy Wolfe Moore, center, sparred over whether delaying the negotiation process over the state’s Medicaid contracts would open the door to possible corruption. Opponents, like Wolf Moore, argue the passing the bill is the equivalent to a one year, no-bid contract extension for the three organizations overseeing KanCare. (Sherman Smith/Kansas Reflector)

TOPEKA — Kansas Republican legislators moved Tuesday to delay negotiations of the nearly $4 billion contracts for insurance companies managing the state’s Medicaid system until 2023.

The bill blocks all requests for proposals for managed care organizations administering KanCare until at least Jan. 1, 2023. The GOP-controlled Legislature was eager to push the process of awarding the new KanCare contracts until January, after the gubernatorial election. 

However, Democrats argued this move allowed no competition and no accountability over the three companies overseeing KanCare. They noted a previous version of the provision heard earlier this year lacked support beyond Republican legislators. 

Opponents also argued the delay would force the equivalent of a no-bid, one year extension of contracts with Sunflower Health Plan, United Healthcare and Aetna Better Health of Kansas, even if it is not delineated in the bill.

“What we are doing here is altering the procurement process for just the three MCOs. Why would we do that?” said Kathy Wolfe Moore, D-Kansas City. “That’s kind of a slippery slope. How many other times is the Legislature going to get involved in this? This is black and white. This is not right.”

Representatives approved the measure 84 to 38, following the lead of the 26 senators who cast affirmative votes before adjourning the regular session in early April. Gov. Laura Kelly has not yet expressed if she will act to veto the measure. The bill was a vote shy of a veto-proof majority in the Senate.

The bill also contains an unrelated section limiting Kelly’s power to close or restrict capacity at Kansas churches during a state of emergency. Legislators combined both measures into the new bill during a conference committee last month.

Rep. Brenda Landwehr, R-Wichita, insisted the new language would not require an extension of current contracts and argued the proposal would ease concerns from the state’s Medicaid director.

She also questioned Kelly’s desire to have the KanCare system managed by nonprofit entities. She argued the current for-profit organizations overseeing KanCare have done a good job providing services. 

“I don’t care if they are profit or nonprofit,” Landwehr said. “What I care about is the citizens that we serve get their services and they get them without interruption. That’s why I’m here.”

Rep. Sean Tarwater, R-Stilwell, called into question Kelly’s handling of previous RFPs and issues in other departments. He lambasted the governor for her handling of the strain placed on the state’s beleaguered unemployment system and said he could not be sure she would manage this better.

Tarwater also noted that Nebraska put out a similar request for proposal a few weeks ago with a deadline of the end of the year.

“It’s a simple process,” he said. “It can be done in a shorter time period, and it can be done properly.”

Kelly is running for reelection in 2022 and should she lose, control over these KanCare contracts would likely go to presumptive Republican opponent Derek Schmidt. Schmidt, the state’s attorney general, previously weighed in on the issue, saying the Legislature did have the authority to delay this process. 

Rep. John Carmichael, who previously ripped this tactic as a corrupt, “pay-to-play” scheme, asked lawmakers to remember the 2014 investigation into whether KanCare contributors paid off lawmakers.

“Where did this idea come from? Who is the proponent of this idea?” the Wichita Democrat asked. “No one can explain a good, legitimate reason to do this.”

House and Senate leadership have denied any misconduct in seeking to delay the contracts.

Carmichael also argued the Kansas constitution already enshrined the ultimate right to practice religion and passing the provision barring the governor from closing churches would simply be duplicative.

However, House majority leader Dan Hawkins, a Wichita Republican, said the governor “closed” churches early in the pandemic, thus requiring this measure. Kelly didn’t close churches, but did issue an executive order limiting mass gatherings in houses of worship.

“It’s important for us to do this because she did not listen to the constitution,” Hawkins said. “Maybe she’ll listen to the statue, maybe she won’t, but it will be in two places now.”

 
 

 
 

Clipped from: https://kansasreflector.com/2022/04/26/legislature-delays-negotiations-of-4-billion-kansas-medicaid-contracts-until-2023/

 
 

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PSD rejoining Colorado’s Medicaid reimbursement program

[MM Curator Summary]: A CO school will re-sign up to get Medicaid funding for healthcare services after a 10 year break and starting a new plan on how to manage the funding stream.

 
 

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.

 
 

After a hiatus of more than a decade, Poudre School District is rejoining Colorado’s Medicaid reimbursement program for school districts. Through the program, PSD will receive partial reimbursements from the state for the cost of providing Medicaid-eligible health services to some students. 

Reimbursements to PSD will be based on the cost of delivering services given by eligible service providers — including nurses, social workers, health aides, occupational therapists and more — but it is not limited to services provided to students who are enrolled in Medicaid individually. Rather, the program partially reimburses health services provided to general education students who qualify through certain health or behavioral plans. 

The program will serve as “a sustainable source of funding that supports the enhancement and expansion of mental and physical health services in schools,” according to a presentation recently given to the Board of Education.

The money the district receives in reimbursements must be spent on health services for all PSD students, not just those who receive the reimbursement-eligible services. This shift is something PSD spokesperson Madeline Noblett said was one of the main reasons the district wanted to join the program again now. 

“We’re really looking at this as an opportunity as a district to be able to grow revenue to support all of our students,” she said, adding that the “mental, social, emotional (and) academic needs of kids have increased.”

“Our needs have continued to increase every year, and our staff are doing incredible work, but they are stretched thin, and they’re supporting so many kids … So we’re constantly just looking to see what the resources available to us are that we may not already be tapping into.”

Though PSD’s new Medicaid Coordinator Corey Henry said they haven’t yet determined what this money will be spent on, it can be used for things such as hiring additional nurses or mental health staff, getting more equipment or engaging with outreach workers to connect families to their needs. A requirement of the program is that the district form a team to assess its needs and how best to spend the money. 

Currently, PSD has just 14 nurses for its 53 schools, according to Kim Granger, health services coordinator.  

“It just feels like the right thing to do to not leave money on the table when we’re (already) providing the services,” Granger said. “It was kind of a no-brainer in my mind.”

How are PSD students doing?:From attendance to social emotional skills, here are 5 takeaways from PSD’s annual report

PSD was most recently a participant in the Medicaid program in 2009. In the 2016-17 school year, former Superintendent Sandra Smyser considered rejoining the program but ultimately put it on hold.

Noblett said that back in 2009, the district left the program because leaders felt it wasn’t “as expansive as possible for the ultimate amount of money that we were generating as a district.” 

However, the program has since started using a cost reconciliation method to calculate reimbursements and, in 2020, it expanded to include reimbursement for Medicaid-eligible health services to more students. Prior to that change, the program allowed reimbursement based on care given to students with individualized education plans or individualized family service plans, but it now includes students with 504 plans, behavior intervention plans and other health care plans, Noblett said.

These changes streamlined the program and allowed districts to claim more costs for the health services they provide to students, according to district officials. 

For subscribers:31 charter schools closed in the last decade. Still, school choice demand is peaking.

When will the program be in place?

PSD expects the program will be fully in place by Oct. 1 this year, but it won’t see regular revenue to cover the initial investment costs for about three years. The only initial investment required by PSD was the cost to fund Henry’s position and an administrative assistant to help get the program running.

Though district officials cannot predict the exact amount of money it will bring in annually until closer to that three-year mark, neighboring districts and those of similar size have received anywhere from $1.2 million to $2.5 million.

Over the summer, Henry and her implementation team will work to create training schedules for staff, have orientation for administrative teams and begin program training in August and September.

Henry and Granger expect that the biggest change for current PSD providers will be the kind of documentation required to access the reimbursement money, though it’s too early to know what the day-to-day lift will look like. 

“There will be some (service providers) with larger caseloads that will probably have more time to spend on their documentation, and some of that won’t take as much time as they think,” Granger said. “I think there’s a ton of fear out there that it’s going to take a huge amount of time, (but) the program is different than what they knew before.”

In the meantime, the biggest lift for Henry and her team will be supporting the staff throughout training and ensuring they understand their roles in the program moving forward. 

“We’re really hoping to make this as successful as possible, build a program where staff feels supported through training, have clarity around what their work looks like as service providers and really, again, generate money that PSD has not been accessing so that we can help our students,” Noblett said. 

PSD news:Liberty Common Elementary School announces expansion, likely into former charter building

Molly Bohannon covers education for the Coloradoan. Follow her on Twitter @molboha or contact her at mbohannon@coloradoan.com. Support her work and that of other Coloradoan journalists by purchasing a digital subscription today.

 
 

 
 

Clipped from: https://www.coloradoan.com/story/news/2022/04/26/psd-rejoining-colorados-medicaid-reimbursement-program/7374814001/

 
 

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Biden administration drops fight over Texas’ Medicaid waiver

[MM Curator Summary]: Biden backs down and Texas safety net providers start to recover from 12 months of uncertainty caused by the unprecedented political power-grab use of CMS.

 
 

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.

 
 

Debate over the waiver was key to the federal government’s push for Texas to expand Medicaid for more working poor.

 
 

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A federal health care program that Texas uses to help pay for health care for uninsured Texans — worth billions of dollars annually — is safe for another decade after the federal government said Friday that it would stop fighting the Trump-era agreement to extend the program beyond its expiration date later this year.

“It is not the best use of the federal government’s limited resources to continue to litigate this matter,” reads a letter sent Friday to state health officials from the U.S. Centers for Medicare and Medicaid Services. “This should resolve the issue without the need for further litigation and will create no disruption to the people who rely on Texas’ Medicaid program.”

The announcement concludes a yearlong legal battle over the so-called 1115 waiver, specifically how long it should stay in effect and how parts of it should be funded.

U.S. Sen. John Cornyn said that while he was glad the Biden administration dropped its efforts to block the waiver’s extension, he blamed it for a “boneheaded move” that did nothing but hurt Texans.

“Medicaid funding is vital for Texas’ most vulnerable, and the Biden Administration’s original decision put their care in jeopardy,” Cornyn said in a prepared statement. “This move would have been damaging during normal times, but following two unprecedented years for health care providers and patients it was downright ruthless.”

Texas Gov. Greg Abbott also criticized the federal government’s opposition to the waiver extension but welcomed the Friday decision to let it continue until 2030.

“The original rescission by the Biden administration last April obstructed healthcare access for vulnerable Texans and took away crucial resources for rural hospitals in Texas, and I am grateful that Texans will now continue to have access to the health care resources they need.”

Texas hospital officials expressed relief that the future of the waiver was no longer in question but continued to push for other programs to help pay for the care of Texas’ uninsured population — the largest in the nation.

“While funding, staffing and COVID-19 continue to challenge hospitals, we look forward to having a solid foundation to work from and rebuild,” said John Hawkins, president and CEO of the Texas Hospital Association. “The long-term health of our safety net must remain strong, and we will continue to underscore the need for coverage expansion, rates that more closely match the cost of care, and a stable uncompensated care pool.”

The waiver was initially set to expire this October, but in the waning days of his administration in 2021, President Donald Trump granted a 10-year extension — a move some healthcare advocates said was a way to provide political cover for Republicans who have refused to expand its Medicaid program to include more working poor adults.

Shortly after, under the Biden administration, which has been pressuring Texas and 11 other states to expand Medicaid coverage to more people, CMS rescinded the agreement in April 2021.

Texas Attorney General Ken Paxton
sued to reinstate it last May, saying moves to shut it down were nothing but a political ploy by President Joe Biden to pressure the state into expanding Medicaid in order to continue helping hospitals care for the uninsured.

A majority of Texans support expanding Medicaid to include millions more mostly working poor people, according to recent surveys.

Paxton won a temporary victory from a federal judge in August, who ordered that the extension stay in place while the feds and the state negotiated over the details of the waiver.

The Friday decision means that the CMS action last April is rescinded and that the waiver extension stays in place without further litigation.

The agreement was meant to be temporary while Texas transitioned to an expanded Medicaid program under the Affordable Care Act of 2010, but that never happened because the U.S. Supreme Court ruled in 2012 that states couldn’t be forced to expand Medicaid. The agreement is up for review every few years.

Since then, the state has relied on the waiver for various programs to care for Texas’ uninsured, with Republican state leaders frequently leaning on it in their arguments against Medicaid expansion.

Texas has the nation’s highest number of uninsured residents, estimated at 5 million, and also has the country’s biggest share of residents — at least 18% — who are not covered.

When uninsured people show up in emergency rooms, the hospitals care for them and then are reimbursed in part by the 1115 Medicaid waiver, which has brought some $30 billion to Texas in the past decade for uncompensated care, mental health programs and similar services.

Staff writer Abby Livingston contributed to this story from Washington.

Disclosure: The Texas Hospital Association has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.

 
 

 
 

Clipped from: https://www.texastribune.org/2022/04/22/texas-medicaid-waiver/

 
 

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CAO overbilled Medicaid $18.16 at a time; files $1M lawsuit for being ‘lulled into complacency’

[MM Curator Summary]: A substance abuse provider is suing its software vendor, claiming the software vendor is at fault for $1M in overbillings to the state.

 
 

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.

 
 

 
 

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Patrick Lakamp

An $18.16 mistake – made over and over again – has put the Community Action Organization of Western New York in a half-million dollar bind.

The organization mistakenly added a weekly charge of $18.16 when billing Medicaid for many of those in its outpatient chemical dependence services program, according to an audit by the New York State Office of Medicaid Inspector General.

Extrapolating the mistaken charge for all 271,809 claims during a three-year audit period, the audit estimated the CAO overcharged the government potentially as much as $992,268.

The office said the CAO could settle the matter by paying back $491,508. But the nonprofit, which spends millions of state and federal dollars fighting poverty, spent the improper reimbursements and does not have the money to repay the amount, according to a lawsuit it recently filed in State Supreme Court.

The CAO blamed the overbilling on its software vendor, TenEleven Group Inc. of Amherst. The lawsuit alleges the vendor “lulled CAO staff into complacency by making false and misleading representations.”

The lawsuit seeks “not less than $1 million” from TenEleven Group. 

“The complaint speaks for itself,” said attorney James J. Zawodzinski Jr., who represents the CAO. “Because the matter is in litigation, we are limited in the comments we can make.”

The lawsuit relates to billings and services provided by TenEleven Group from 2014 to 2016.

“Audit findings are common, and these findings are a relatively small percentage of the agency’s overall billings,” Zawodzinski said. “The litigation seeks to recover the resulting audit finding from the software vendor who the complaint alleges made errors which caused the bulk of the audit finding.”

TenEleven Group said it’s not responsible for the mistaken billing.

“CAO’s lawsuit is nothing more than a deflection tactic, seeking to cast blame on a third party for CAO’s own failure to ensure it followed proper billing practices and appropriately handled public funds,” the company said in a statement. “TenEleven merely provided software to CAO, and is not, nor was it ever responsible for CAO’s billing, processing, accounting, or reporting practices to state and federal agencies. We believe the lawsuit is meritless and intend to vigorously defend against the allegations in the complaint.”

It is not clear from the CAO’s lawsuit whether any overbilling occurred after the audit period, and if so, how much. If the improper $18.16 charges continued after the audit period, the organization has the ability to report overpayments through the inspector general’s self-disclosure program.

Thomas Kim, president and CEO of the CAO, did not return messages seeking more information about the overcharges.

“To date, TenEleven Group has not responded to, in any meaningful fashion, CAO’s attempts to resolve the present dispute,” according to the CAO’s March 22 lawsuit.

The Office of Medicaid Inspector General audited a random sample of claims from January 2014 through December 2016 submitted by the CAO’s Drug Abuse and Treatment Program. In all, the program submitted 271,809 claims totaling $7.9 million during the period.

 
 

Audit of CAO opioid treatment program


New York State’s Medicaid inspector general audited a random sample of Medicaid claims submitted the the CAO of Western New York’s Drug Abuse …

Most of those receiving services in the program are enrolled in Medicaid, the federal-state health care insurance program that helps pay for health care for low-income people of any age.

When the DART clinic provides services to those on Medicaid, it bills Medicaid for reimbursement.

For years before the audit, TenEleven Group provided software to CAO under an agreement that both sides modified from time to time. In May 2014, TenEleven Group and CAO amended it to put in place “an enhanced suite” of software and services, according to the lawsuit. The software included an upgraded billing component enabling reimbursement claims to be submitted electronically.

In its lawsuit, the CAO said it paid “substantial sums” for the software package, including licensing fees and ongoing maintenance costs.

The CAO, according to the lawsuit, relied on, and continues to rely on, TenEleven Group’s software to manage billings, primarily for the Medicaid program. CAO employees continue to input weekly billings for services provided to DART clinic patients into the TenEleven Group billing and financial module. TenEleven Group’s software transmits the nonprofit’s claims to the electronic Medicaid New York claims system portal in CAO’s name for payment directly to CAO, according to the lawsuit.

Staff at the DART clinic became aware the software had “a significant defect” after using the upgraded software for a period of time, according to the lawsuit. After learning of the $18.16 additional weekly charge, the staff alerted TenEleven Group, according to the lawsuit. Either an error in the software or in the billing submissions protocol appeared to trigger additional payments from Medicaid for which the CAO had not submitted claims for reimbursement.

TenEleven Group investigated the source of the overcharges and offered assurances the DART staff was correctly inputting claims information, according to the lawsuit.

TenEleven Group told the CAO that it had identified the cause of the defect and addressed it with Medicaid and “repeatedly assured” the CAO that the billing software “was functioning properly” and transmitting accurate information to the eMedNY claims system, according to the lawsuit.

The CAO renegotiated its agreement with TenEleven in 2018, paying higher services fees to continue using the software.

The CAO’s lawsuit alleges TenEleven Group “fraudulently induced CAO to continue as a customer … despite knowing that they had not mitigated the defect CAO previously brought to their attention.”

“TenEleven failed to disclose what is now apparent: that whatever actions TenEleven, through its representatives, may have been taking, those actions were not effective either to rectify the software defect or to reduce CAO’s now-expanding liability to the Medicaid program,” according to the lawsuit.

The CAO received $36.9 million in government grants, according to a 2019 tax filing.

The CAO in 2018 served 642 people in its outpatient opiate treatment clinic, according to the tax filing. The DART clinic conducted 177,252 dispensing visits and 14,883 “clinical episodes of care” that year, and it reported that 78% of those in the program established and maintained abstinence from drug and alcohol use.

 
 

 
 

 
 

Clipped from: https://buffalonews.com/news/local/cao-overbilled-medicaid-18-16-at-a-time-files-1m-lawsuit-for-being-lulled-into/article_7b831d6e-bfef-11ec-9cdf-5b3a7455ded0.html

 
 

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New York State budget expands Medicaid eligibility for older adults

[MM Curator Summary]: A new change in the NY budget process will allow older members to make more money and have more in assets and still have Medicaid coverage. It will also give non-citizens over 65 Medicaid coverage, but those members will have to be paid for using zero federal dollars.

 
 

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.

 
 

New York State Department of Financial Services

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Bronx nursing home resident James Galbert receives his first dose of the COVID-19 vaccine in December 2020.

Reaction to the 2023 New York State budget continues, and older adult advocates are pleased that the $220 billion plan passed by lawmakers earlier this month expands Medicaid eligibility.

Starting in 2023, older, disabled and blind New Yorkers can make up to 138% of the federal poverty level and still qualify for taxpayer-funded health care coverage. That would increase the maximum monthly income for those groups from $934 a month to $1,563 a month.

“So what this is going to do is massively expand the reach of the Medicaid program for folks, specifically in the age, blind and disabled categories of eligibility,” said attorney Kelly Barrett Sarama with the Center for Elder Law and Justice, a Buffalo nonprofit legal agency.

In addition, the maximum assets those groups can have and still qualify for Medicaid will nearly double, from $16,800 to $28,134. For couples, the allowable maximum assets will increase from $24,600 to $37,908.

Under the current limits, Sarama said many people have to spend down much of their assets in order to qualify for Medicaid. Plus, she said, many younger Medicaid recipients, who are not subject to an asset test, lose their coverage once they move into the older, disabled or blind categories.

“What this increase will do is help protect folks who do have a bit of a retirement savings and who have a little bit of resources in their account from completely being forced to deplete their income and assets in order to qualify for Medicaid,” she said.

The budget also makes Medicaid available to undocumnted immigrants 65 and older, as well as extends postpartum coverage for Medicaid-eligible mothers from 60 days after they give birth to one year after they give birth.

One in three New Yorkers, 7.4 million people, are currently on Medicaid, including over 280,000 in Erie County. That number has increased by about 1 million since the COVID-19 pandemic began, as the economic recession made more people eligible and federal laws barred states from terminating coverage for most enrollees during the public health emergency.

Gov. Kathy Hochul’s office did not immediately respond to an inquiry about how many more New Yorkers are expected to be on Medicaid once eligibility expands next year. In December, the state Division of Budget had projected Medicaid enrollment to return to pre-pandemic levels of just over 6 million by 2024.

New York already has the second-largest Medicaid budget of any state in the nation, with total spending at $72.8 billion in 2020. Only Californida, with a $97.8 billion Medicaid budget, spent more.

The funding is crucial, Sarama said, as it’s the primary payer of long-term care in the state. Medicaid accounts for nearly 80% of New York nursing homes’ revenue and determines the wages of the state’s home care workers.

“As you age, you’re more likely to end up needing some care in your home in order to sustain your lifestyle and to remain living in your home, and so this increase will help more folks access the Medicaid program, access long-term care in New York State,” Sarama said.

 
 

 
 

 
 

Clipped from: https://www.wbfo.org/health-wellness/2022-04-24/new-york-state-budget-expands-medicaid-eligibility-for-older-adults

 
 

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Illinois Gov. JB Pritzker has law that would expand Medicaid coverage

[MM Curator Summary]: She doesn’t really emphasize that expanding to non-citizens will have to be paid 100% by state taxes.

 
 

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.

 
 

 
 

 
 

 
 

A bill that would expand Medicaid coverage to otherwise ineligible noncitizens is now awaiting Gov. JB Pritzker’s approval.

That provision was part of an “omnibus” Medicaid bill, House Bill 4343, that passed through the General Assembly on the final day of the session.

And while Medicaid bills are traditionally worked out in a bipartisan “working group,” this one drew strong opposition from Republicans because the language about noncitizens had never been discussed in any public hearing or working group meeting.

“We had a bipartisan group for the last three months, getting up at 7 o’clock in the morning for these meetings with the agreement that all Medicaid expansions and increases were going to be working through this group,” Sen. Dave Syverson, R-Rockford, said during floor debate in the Senate. “And then you turn around a couple hours after this agreement, and you change the bill.”

More:What’s in Illinois’ $46 billion budget package? Here’s a detailed look

Sen. Ann Gillespie, D-Arlington Heights, who chairs a Medicaid subcommittee, defended the process and said there were other provisions of the bill that were negotiated outside the working group.

“We used this bill to add on the Medicaid omnibus, but it was never exclusively the Medicaid omnibus,” she said.

She said the bill clarifies statutory language to help providers and meets a goal of expanding health care coverage amid the pandemic to “make sure that we’re taking care of as many people as we can.”

In 2020, Illinois became the first state to offer coverage for undocumented noncitizens by extending it to those 65 and older who would otherwise qualify for Medicaid if not for their immigration status. In 2021, lawmakers lowered the age limit to 55. This year’s bill lowers the age limit even further to 42.

In addition, Illinois does not apply a citizenship requirement for children under age 18 or pregnant women, including up to 60 days postpartum.

Medicaid is a government-funded health care program for low-income individuals and families. It is jointly funded with state and federal dollars and is administered by the state under federal guidelines.

Under federal rules, certain categories of noncitizens can qualify for Medicaid if they are lawfully present in the country. Among those are green card holders, asylees, refugees and members of federally recognized Native American tribes who were born in Canada. Those individuals typically must be U.S. residents for five years before they become eligible.

But federal rules do not allow for coverage of those who are not lawfully present in the U.S., which means the federal government will not reimburse for their care and all costs of covering those individuals must be paid solely with state dollars, estimated at $68 million a year for the latest expansion.

More:How the top Illinois governor candidates are outpacing others in fundraising and spending

Covering noncitizens

Supporters of covering noncitizens regardless of their immigration status argue that it’s actually cheaper than the alternative, which is forcing them to get all of their care in emergency rooms.

“These are people that would have otherwise ended up in the emergency room because of their diabetes, or because of high cholesterol in the midst of a pandemic,” said Rep. Delia Ramirez, D-Chicago, who sponsored a separate bill, House Bill 4437, that would have extended coverage to all noncitizens age 19 and over. “And the cost of not insuring them was 3-to-1 to insuring them right now.”

But Syverson rejected that argument and said there is a bigger danger in providing an inducement for people to come into the country illegally with the offer of taxpayer-funded free health care.

“If the word’s out that Illinois is the place to go, they’re going to come here, and like I said before, we can’t adequately take care of our disabled and our seniors,” he said in an interview. “And yet, we’re going to provide better care for undocumenteds than we do for our own families. And it’s going to drive up the cost of health care for working families, because again, the more people that are on government health care that reimburses at a much lower rate to hospitals and doctors, the more that gets shifted over to private-pay people.”

Gillespie said during a separate interview that the idea of expanding coverage for more noncitizens grew out of a feasibility study directed by the governor’s office through the Departments of Healthcare and Family Services and Insurance.

That study examined several options for reducing the number of uninsured people in Illinois and making coverage more affordable.

The report, released in April 2021, led to the formation of another working group focusing on health care expansion, Gillespie said, and that was the group that came up with the language to expand coverage to more noncitizens.

“So the base of House Bill 4343 was the results coming out of that group,” she said. “And then we added the Medicaid working group provisions, agreed provisions, onto that bill. So the bill itself had two separate geneses, if you will.”

Expanding Medicaid coverage to more noncitizens was also a top priority of the Legislative Latino Caucus.

Speaking at an April 5 news conference to promote her own bill, Ramirez argued that providing universal coverage was the morally right thing to do.

“This would finally ensure that every single low-income person in our state has access to health care coverage, regardless of their immigration status,” she said. “Health care must be a human right. Everyone should be able to access a doctor to treat their diabetes or manage a chronic condition regardless of their immigration status.”

Ramirez’s bill was never voted on by a committee, but discussions about expanding coverage for more noncitizens continued until the cutoff age of 42 was agreed upon.

“And that’s where the budget discussions came in. It really came down to what was it that we could afford to do this year,” Gillespie said.

Working groups

The process by which the bill passed the General Assembly highlights a little-known and often obscure aspect of the General Assembly, informal “working groups.”

Under the Illinois Constitution, all meetings of committees, joint committees and legislative commissions must be open to the public. Committee meetings may be closed if two-thirds of the members of that chamber determine that it’s in the public interest to do so. Closing joint committee and legislative commission meetings requires a two-thirds vote in both chambers.

In recent years, however, lawmakers have gotten around that by forming informal “working groups” that operate much like committees in that they study issues, hear testimony and recommend the passage of legislation. But their meetings are not open to the public and even their membership is not publicly known.

Lawmakers on both sides of the aisle have defended the working group process, saying it allows for more free discussions and that ultimately it leads to bipartisan legislation.

“Over the past several years, the Medicaid work group has been a really productive and collaborative experience for members of all four caucuses and the administration, no matter which party was in control the governor’s office, to work through complicated issues in the Medicaid space, and to evaluate a wide range of options that were brought before the House,” Rep. Tom Demmer, R-Dixon, said during debate in the House.

Demmer said bills crafted through that process have often received unanimous support.

“Unfortunately, the bill that we see before us today has many items we did talk about and reach consensus on, but others that were simply added at the last minute and for that reason, I urge a no vote,” he said during debate.

Capitol News Illinois is a nonprofit, nonpartisan news service covering state government and distributed to more than 400 newspapers statewide. It is funded primarily by the Illinois Press Foundation and the Robert R. McCormick Foundation.

 
 

Clipped from: https://www.sj-r.com/story/news/state/2022/04/25/illinois-gov-jb-pritzker-has-law-would-expand-medicaid-coverage/7414341001/

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TennCare legislation requires renewal with providers that didn’t win contracts

[MM Curator Summary]: Legislators in TN are looking for a way to guarantee incumbents keep their dual eligibles contracts even after losing the larger Medicaid contracts.

 
 

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.

 
 

 
 

Speaker of the House Cameron Sexton backed addition of Centene Corp. to TennCare through a no-bid contract. (Photo: John Partipilo)

Insurance conglomerate Centene, which has spent more than $1 billion to settle Medicaid lawsuits across the nation, could still get a shot at a TennCare contract it failed to win.

The bill’s sponsor wants to make sure TennCare recipients enrolled in a Medicare-Medicaid program are able to stay with their insurance carriers, including Centene and two others that didn’t receive a new contract, Cigna and Humana.

House Bill 2625 by Rep. Charlie Baum, R-Murfreesboro, would require TennCare to study the impact of not contracting with Centene and two other insurance companies and report back to the General Assembly. In the meantime, TennCare would take no action to remove the enrollees from their plans for a Medicaid-Medicare coverage program, which includes Centene, Humana and Cigna.

 
 

The legislation is to head to the House floor for a vote after receiving approval Tuesday from the House finance committee. 

It is unclear, though, whether the measure will make it through the full General Assembly. The Senate version sponsored by Sen. Todd Gardenhire, R-Chattanooga, hasn’t been amended and isn’t expected to reach the floor for consideration with the Legislature set to adjourn later this week.

The amendment Baum presented Tuesday in the finance subcommittee didn’t address insurance giant Centene as a managed care organization. Baum said he would not make an effort on the House floor, either, to re-insert Centene into the bill. 

But he said the legislation, as amended, should cover TennCare recipients who have selected Humana, Cigna and Centene. 

Those three companies have been providing coverage for TennCare recipients on the Medicaid-Medicare program, according to Baum, but did not win bids to continue serving.

The three contracts went instead to Americare, BlueCross BlueShield and Universal. 

According to TennCare spokeswoman Amy Lawrence, the portion of the bill dealing with dual enrollees in Medicaid-Medicare is “completely separate” from the managed care organization part previously included. The newest amendment does requires a study but also forces TennCare to renew expiring contracts with all contract contracted dual-coverage providers until the General Assembly adopts a resolution permitting non-renewal, according to Lawrence.

Regardless of what they do, what they tried to do and what they are currently trying to do to cover their tracks, at the instruction of the Speaker, is clear. The message they are sending is: If you don’t like a result, donate.

– Rep. Jason Hodges, D-Clarksville

Baum, who asserted he has not received any campaign contributions from Centene, said his intention was to enable enrollees to maintain their coverage with Centene, Cigna and Humana. He acknowledged the legislation went through several changes, including the effort to give Centene a contract, since it applied for the contract as a managed care organization.

House Speaker Cameron Sexton got behind the legislation and signed on as a co-sponsor, saying he felt the division of TennCare needed more “transparency.” He also objected to the potential removal of enrollees from their “dual-coverage” plans.

State Rep. Jason Hodges, a Clarksville Democrat, challenged the legislation when it surfaced a month ago, calling it a form of “bid-rigging.” The initial amendment also would have cost the state an estimated $2.8 million next fiscal year and $30 million in a third year, in addition to $60 million in federal funds, according to a fiscal impact document.

Hodges, who is not seeking re-election, said Tuesday, “Regardless of what they do, what they tried to do and what they are currently trying to do to cover their tracks, at the instruction of the Speaker, is clear. The message they are sending is: If you don’t like a result, donate. The amendment doesn’t change anything for me.”

Sexton’s office did not respond to questions immediately Tuesday. 

A bill to give a no-bid contract to0 Centene has been withdrawn but bill sponsor Rep. Charlie Baum, R-Murfreesboro. wants to make sure TennCare recipients enrolled in a Medicare-Medicaid program are able to stay with their insurance carriers, including Centene

Centene Management has not contributed money to any lawmakers in the last two years but gave two donations of $4,200 each to Gov. Bill Lee in January 2021. 

The Division of TennCare has opposed the bill, saying it ran a “fair and open process” in its most recent procurement. It also contends no enrollees will lose coverage because they will have plenty of time to switch to a new provider. 

Centene has been pushing hard for the legislation and started pressing the matter this week. Recently, it asked Sen. Kerry Roberts, R-Springfield, to sign on as co-sponsor of the Senate bill, which remains stuck in the Calendar and Rules Committee.

Rhythm Health Tennessee, which is part of Centene Corp., previously filed a protest against the bidding process. It has agreements with several Tennessee health-care providers, including a preferred agreement with Vanderbilt Health Affiliated Network.

Hodges also raised questions about Centene because it was connected to a bid-rigging lawsuit filed against the state.

In May 2021, the Department of Correction opted to take new bids on a $123 million contract for inmate mental health services because of the lawsuit, which was dismissed with prejudice this January. 

Nationally, it has run into several problems as well.

In mid-2021, Centene announced it would spend $1.25 billion to settle disputes with 22 state Medicaid systems, though the company admitted no wrongdoing, according to an Ohio Capital Journal report.

That included $55 million in a settlement with Mississippi for failing to give contractually guaranteed discounts on Medicaid drugs. 

An $88.3 million settlement with the state of Ohio centered on accusations by the attorney general that Buckeye Health, a Centene subsidiary, set up a chain of businesses that double-charged the state for services.

The report also details comments by Centene chief Michael F. Neidorff in June 2021, in which he said the company’s goal is to increase its net income margin by 3.3%, to $120 billion.

 
 

 
 

Clipped from: https://tennesseelookout.com/2022/04/27/centene-guarantee-removed-from-tenncare-contract-legislation/

 
 

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California investigating Centene over alleged Medicaid fraud

[MM Curator Summary]: CA begins its efforts to access the $1.2B set aside by Centene to deal with PBM spread pricing allegations.

 
 

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

 
 

California regulators are investigating Centene Corp. over allegations that the company overcharged the state’s Medicaid department for drugs, according to a state Department of Health Care Services spokesperson.

DHCS did not specify which branch of Centene it was investigating. Centene subsidiaries offer Medicaid managed-care plans in California and administer the state’s Medicaid prescription drug program.

Centene receives the majority of its revenue from Medicaid managed-care contracts, and California represents its largest market with 2.14 million enrollees. In 2021, the state paid Centene $6.8 billion to manage its Medicaid program, the DHCS spokesperson said.

Centene did not respond to an interview request about the investigation.

Centene reached agreements with nine state attorneys general and has reserved $1.25 billion to settle allegations that it overcharged state Medicaid departments for medications, the insurer wrote in its annual filing with the U.S. Securities and Exchange Commission.

It has so far publicly disclosed paying $246.4 million to Illinois, Arkansas, Mississippi, Ohio and Kansas as part of these deals. Georgia, South Carolina and Indiana are also reportedly investigating the insurer over its now-defunct Envolve pharmacy benefit manager. The attorney general in South Carolina declined to comment, while attorneys general in Indiana and Georgia did not respond to interview requests.

California accepted new bids to run its Medicaid managed-care program until April 11, and it will announce winners in August. Centene executives are likely doing everything they can to ensure regulators are satisfied with their response, said Ari Gottlieb, a principal at A2 Strategy Group.

“It’s a highly material part of their business,” Gottlieb said. “My guess is that they’re throwing a bunch of extra resources, apologizing, really going all-in on fixing the problem.”

Existing problems in California

California’s investigation comes as state regulators withheld $3.8 million from subsidiary Magellan Health’s January contract after worker shortages left patients and providers waiting for prior authorization approvals, some of whom were on hold with the company’s call centers for eight hours at a time.

Both state regulators and Magellan Health blamed delays on contract changes, noting that a new vendor was taking over the administration of the state’s Medicaid prescription drug program for the first time. Magellan Health’s $302 million annual contract went live at the start of the year.

Rival insurers criticized the deal, saying the move would give Centene insight into their member demographics and give them a leg up when it came to bidding to run the largest Medicaid program in the nation. Centene’s pharmacy services reputation did not help: Patients and providers noted the irony of hiring a vendor that recently settled drug overcharging allegations from other state Medicaid departments.

“There’s a specter surrounding Centene and its legal troubles with regards to pharmacy benefits,” Antonio Ciaccia, president of drug pricing watchdog 3 Axis Advisors and head of 46brooklyn Research. “While their PBM has taken the disproportionate share of public lashings today, they’re not different from anybody else in this market.”

It’s hard to fault Centene when it recently acquired Magellan Health, and it hasn’t been fully integrated the businesses, Gottlieb said. California regulators approved the $2.2 billion merger two days before Magellan Health took over the state’s Medicaid prescription drug program. Moreover, delays in processing claims and prior authorization requests are common when public health programs change, and formulary updates made at the start of the year could have complicated the process, he said.

“Part of it is on the regulators, honestly, they should be doing their due diligence and readiness assessments to ensure their vendors can perform,” Gottlieb said.

DHCS said it measured the agency’s and Magellan Health’s internal capacities to administer the program prior to launch. Delays processing prior authorization requests, adjudicating provider claims and answering provider and patient calls “have stabilized and all backlogs have been cleared” since the start of the year, the spokesperson said.

Magellan Health has processed all prior authorization requests within 24 hours since February 11, and paid all pharmacy providers on time since the start of the year, a Magellan spokesperson wrote in an email. The company’s call centers levels are currently meeting their contractual requirements, the spokesperson wrote.

Long wait times disproportionately impacted–and continue to impact–the state’s safety net facilities, where up to 60% of their patients are insured through Medicaid, said Isabel Becerra, CEO of the Coalition of Orange County Community Health Centers, a not-for-profit consortium safety net clinics in southern California. While the backlog from the start of the year has been resolved, Becerra said providers are still spending more time than they had before the merger to secure care for their patients.

“It’s still not fixed,” Becerra said. “There’s still a lot of time that’s being taken with these patients.”

Delays cloud Sunshine Health Plan

California is not the only market where providers are complaining of long wait times with Centene. Lags in the company’s payment, claims adjudication and prior authorization systems have also plagued Florida, Centene’s second-largest Medicaid market with 1.78 million enrollees. The deadline to bid on continuing to run Florida’s Medicaid program is also approaching, Gottlieb noted.

In March, Florida regulators fined Centene $9.1 million and suspended enrollment in its Sunshine Health Plan after technology glitches related to its integration of insurer Wellcare led it to mistakenly deny medical claims for more than 121,100 lower-income adults and children.

In response, Sunshine Health agreed to provide a corrective action plan to the state. Since its October merger with Wellcare of Florida, 99.1% of its claims were paid within 30 days, a Sunshine Health spokesperson wrote in an email.

But hospitals and independent providers are still reporting delays, said Mary Mayhew, president and CEO of the Florida Hospital Association.

“A lot of the fallout will continue,” Mayhew said.

One provider still navigating the change in payers is Children’s Orthopaedic and Scoliosis Surgery Associates, which claims to be the state’s largest private children’s orthopedic provider. Sunshine Health Plan owes the independent practice $200,000 over improperly denied claims and prior authorizations, repricing and categorizing consults as new patient visits, administrator Carol Ittig said.

In late March, Ittig said she had a virtual meeting with Centene executives about the payment problems, telling them she would have to delay paying the practice’s physicians because of the insurer’s lag in accurately processing claims. Three days later, Ittig woke up to a $70,000 no-strings-attached loan from Sunshine Health.

“They told me to hold on to it as long as I think that there’s still issues,” she said. “I’m very grateful. But that shows that they know that there are issues, that they want to rectify it but they know that it’s gonna take them a minute to fix.”

 
 

 
 

 
 

Clipped from: https://preparedpatriot.net/2022/04/25/california-investigating-centene-over-alleged-medicaid-fraud/