Tag: State News

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UnitedHealth (UNH) Inflated Drug Costs, Louisiana AG Alleges in Suit

[MM Curator Summary]: UHC is now facing its own spread pricing allegations related to its subsidiary PBM OptumRx.

 
 

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.

 
 

UnitedHealth Group headquarters in Minnetonka, Minnesota.

Photographer: Mike Bradley/Bloomberg

By

John Tozzi

April 20, 2022, 11:09 AM CDTUpdated onApril 20, 2022, 2:04 PM CDT

UnitedHealth Group Inc. was accused by Louisiana’s attorney general of inflating prescription drug charges in the state’s Medicaid program by billions of dollars.

UnitedHealth’s pharmacy benefits manager, Optum Rx, used secret prices and the complexity of the supply chain to cause the safety-net health program “to needlessly pay billions of dollars more per year for prescription drug benefits,” according to a lawsuit from Attorney General Jeff Landry. The action was filed April 13 in state court.

UnitedHealth said in a statement that its services are performed in accordance with state regulations and the Medicaid program’s requirements outlined in its contract. “We believe this lawsuit is without merit and will defend ourselves against these unsupported allegations,” the statement said. 

Pharmacy benefits managers have come under growing scrutiny from employers and governments over how they calculate drug costs. The case is the latest attempt by state authorities to curb what they call fraudulent pricing practices by pharmacy benefits managers hired to run Medicaid drug plans. UnitedHealth rival Centene Corp. took a $1.1 billion charge last year to resolve similar claims from several states.

UnitedHealth is one of several companies Louisiana hired to administer Medicaid, the state-based insurance plan for low-income residents. Contracts require the companies to spend a minimum share of their premiums on medical care, a threshold known as the medical-loss ratio, or MLR.

UnitedHealth also owns pharmacy benefit manager Optum Rx, which contracts with its health insurance plans. The AG alleged that Optum had an incentive to pump up its drug costs to help parent UnitedHealth meet its required spending on health care.

“Since only United is required to abide by the MLR requirement, inflating the drug costs paid to Optum actually helps United meet its MLR but does not create an actual loss to their parent company,” the AG’s filing said. “Inflated payments to Optum are additional profits for United, yet are counted as costs for the purposes of meeting the MLR.”

The petition alleges that Optum overcharges the state for generic drugs; engages in spread pricing by charging the state more than it pays pharmacies to fill prescriptions; and claws back money from pharmacies without passing it back the state.

“Unregulated middlemen, cloaked in secrecy, drive up their own profits at the expense of Louisiana citizens,” Landry said in an emailed statement. He alleged that PBMs take advantage of “an unclear web of contracts” with drugmakers, health plans and pharmacies, “taking a share of profits from each entity.”

The action cites a breach of contract, violations of the Louisiana Unfair Trade Practices Act and other violations. In addition to damages, restitution, and penalties, the AG asked the court to force United to turn over documents that the state requested during its probe but was unable to obtain.

The case is State of Louisiana vs. OptumRx and United Healthcare of Louisiana Inc., C-717848, East Baton Rouge Parish.

(Updates with attorney general’s statement in ninth paragraph)

 
 

 
 

 
 

Clipped from: https://www.bloomberg.com/news/articles/2022-04-20/unitedhealth-inflated-drug-costs-louisiana-ag-alleges-in-suit

 
 

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Consulting firm that worked for the feds had conflicts. What about another that worked for Ohio?

[MM Curator Summary]: Another state is questioning the revolving door and interconnected relationships between large health plans and other state contracts with global consulting forms.

 
 

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.

 
 

 
 

Ohio Medicaid Director Maureen Corcoran (left) before the start of the Joint Medicaid Oversight Committee Meeting at the Ohio Statehouse, October 27, 2021, in Columbus, Ohio. (Photo by Graham Stokes)

Can Ohioans be confident that a consulting firm paid almost $10 million by taxpayers last year to assist in a $22 billion procurement didn’t have conflicts of interest? 

The firm hasn’t answered whether any of the Medicaid managed-care bidders were also its clients. And Ohio officials don’t appear to have much interest in digging out or publicizing that information.

After the New York Times last week reported that a separate global consulting firm appeared to have rampant, undisclosed conflicts with the federal government and with opioid makers, the Ohio Department of Medicaid last week didn’t answer directly when asked if its consultant should disclose its clients. The consultant, Mercer, wouldn’t say, either.

The Medicaid department last year hired the company to facilitate a process by which it hired six managed-care firms for the next five years. Controversially, the process Mercer set out prohibited evaluators from considering that some of the companies had been accused of defrauding Ohio taxpayers. One of the successful bidders had just agreed to pay Ohio $88.3 million to settle fraud claims, and another is still being sued by the state on claims that it defrauded taxpayers of $16 million.

While the process didn’t consider allegations of fraud, it asked for pitches involving things that are less tangible.

“We wanted resourcefulness,” Ohio Medicaid Medical Director Mary Applegate testified last year during litigation over the procurement, describing what the department wanted to hear from bidders. “We wanted patient-centeredness. We wanted a new paradigm of what ‘managed care’ means.” 

Federal rules around rate setting are now so strict that there is little competition on price during Medicaid managed-care procurements, said Kip Piper, a former Wisconsin Medicaid director and former senior advisor at the U.S. Centers for Medicare and Medicaid Services. Instead, the procurements tend to be beauty contests in which the companies with the most resources win because they put together the slickest packages, he said.

“It’s pretty close to the time that procurements of Medicaid plans actually provide no value,” Piper said in an interview last month, adding, “What you often end up getting is a huge team of people — it’s staggering how these big proposals are put together — and it’s a huge industry putting together these proposals. Whoever writes the best proposal wins.”

Indeed, two of the winners of multi-billion-dollar deals — the same two that have been sued by the state — are among the 25 largest corporations by revenue in the United States.

Meanwhile, Mercer has refused to say whether any of the bidders does other business with it. As part of last year’s litigation, the Medicaid department eventually produced a memo addressing the possibility of Mercer conflicts, but Franklin County Common Pleas Judge Julie M. Lynch allowed the department to redact the names of Mercer’s clients.

Seeing those names seemed to take on new urgency last week.

The New York Times reported that the U.S. House Committee on Government Oversight and Reform is preparing a report on conflicts that a separate consultant, McKinsey & Company, had as it simultaneously consulted for opioid manufacturer Purdue Pharma and the U.S. Food and Drug Administration. 

Despite claiming it had strict firewalls to protect against conflicts, the firewalls appear to have been porous at best.

Documents show that some of the same McKinsey employee consulted with Purdue Pharma — which has paid out billions over its role in the opioid epidemic — while also consulting with the U.S. Food and Drug Administration about how it approved new drugs, some of which Purdue wanted to bring to market.

The apparent conflicts didn’t end there.

McKinsey in some instances watered down recommendations to its FDA clients after objections from consultants for its pharma clients, the report said. And McKinsey even boasted of its access to FDA officials through its federal contracts when pitching services to pharmaceutical clients, the documents show.

In a statement, Committee Chairwoman Carolyn Maloney, D-New York, said the investigation shows that the consulting industry is sorely in need of transparency.

“The Oversight Committee’s investigation is shining a spotlight on the unregulated and secretive world of private consulting firms like McKinsey that create conflicts of interest by working for both the federal government and regulated industries,” she said. “Today’s report shows that at the same time the FDA was relying on McKinsey’s advice to ensure drug safety and protect American lives, the firm was also being paid by the very companies fueling the deadly opioid epidemic to help them avoid tougher regulation of these dangerous drugs.”

In light of the seemingly rampant conflicts of interest at McKinsey, wouldn’t it make sense for Ohio Medicaid to release a client list from Mercer, the consultant it paid $10 million to help it dole out $22 billion worth of contracts?

Ohio Attorney General Dave Yost was one of 47 state attorneys general to sue McKinsey over its role in encouraging Purdue to “turbocharge” opioid sales as the epidemic killed 450,000 Americans. The case against McKinsey netted a $600 million settlement.

In an email last week, Yost said the McKinsey conflicts were unsurprising.

“I was disturbed — but not shocked — to read about these conflicts in the prescription drug space,” he said. “There’s a huge potential for conflicts of interest in health care, especially given the rapid consolidation and vertical integration of systems.”

Yost added that, “We are witnessing the development of a system that works against and not for Americans and it’s a system crying out for significant reform.”

But Yost referred questions about Mercer to the Medicaid department. Asked whether Medicaid Director Maureen Corcoran believes Mercer should disclose its clients, spokeswoman Lisa Lawless in an email said, “Medicaid’s robust protections in the procurement were heard by the court during last fall’s trial related to a challenge by one losing bidder.”

Then she quoted a lengthy passage from a ruling Judge French wrote after denying a motion to publicly name Mercer’s clients. In it, the judge expressed trust in Mercer’s firewalls.

“The evaluators received extensive training on how to review applications from Mercer,” it said. “The entities that assisted Medicaid with the (managed care) procurement walled off their procurement teams from other departments and individuals.”

Clipped from: https://ohiocapitaljournal.com/2022/04/19/consultant-that-worked-for-the-feds-had-conflicts-what-about-another-that-worked-for-ohio/

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Pueblo West clinic Springbok Health settles fraudulent Medicare claims

[MM Curator Summary]: Springbok Health will pay up to $335k for upcoding simple services to get paid as if they were complex medical services.

 
 

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 substance abuse treatment clinic in Pueblo West has agreed to pay at least $125,000 to resolve allegations by the Colorado U.S. Attorney’s Office that it violated the False Claims Act by billing Medicare and Medicaid for complex medical services that were never rendered.

Springbok Health Inc., a clinic with locations in Colorado Springs and Pueblo West, and its owner and CEO Mark Jankelow, agreed to pay at least $125,000 and as much as $335,494 in the settlement, the Colorado U.S. Attorney’s Office said in a statement.

The claims settled by the agreement are allegations only, according to the U.S. Attorney’s Office, and do not reflect a determination of liability. The resolution is based on Springbok’s and Jankelow’s ability to pay.

From 2017 to 2019, Springbok allegedly billed Medicare and Medicaid for “expensive medical evaluation and management services when, at most, less expensive counseling services were provided,” the statement said.

More in legal news:Pueblo woman awarded $20,000 in discrimination lawsuit against medical practice

“Billing Medicare and Medicaid for more expensive services than were actually rendered depletes the limited resources of these vital health care programs,” Principal Deputy Assistant Attorney General Brian M. Boynton said in the statement. “We will continue to safeguard taxpayer dollars and hold accountable those who knowingly misuse such funds.”  

“Providing substance abuse treatment is a vital tool in combating the opioid epidemic devastating Colorado communities,” said U.S. Attorney Cole Finegan for the District of Colorado. “But offering treatment to addicts does not excuse fraud. Our office will continue to pursue claims against providers whose fraudulent billing practices take valuable resources away from victims of the opioid crisis.”

The False Claims Act, which Springbok and Jankelow were accused of violating, is a federal law that imposes liability on companies and individuals who defraud governmental programs. It dictates that violators are liable for treble damages — damages up to three times actual or compensatory damages awarded to a prevailing plaintiff — plus a penalty that is linked to inflation. 

Pueblo public safety:Pueblo Police searching for suspect in Good Friday homicide

In addition to allowing the U.S. government to pursue perpetrators of fraud, the FCA allows private citizens to file suits on behalf of the government in “qui tam” suits against those who have defrauded the government. 

Private citizens who successfully bring qui tam actions may receive a portion of the government’s recovery.

The civil settlement with Springbok includes the resolution of an action brought under the qui tam or whistleblower provisions.

The citizen who brought the action, identified in the U.S. Attorney’s Office statement only as “Ms. Chaudhry,” will receive at least $22,500, and up to $60,389 as her share of the settlement.

Springbok and Jankelow could not be reached for comment by The Chieftain’s press deadline Tuesday.

Chieftain reporter Zach Hillstrom can be reached at zhillstrom@gannett.com or on Twitter @ZachHillstrom 

 
 

Clipped from: https://www.chieftain.com/story/money/2022/04/19/pueblo-west-springbok-health-clinic-settles-medicare-medicaid-fraud-claims/7368884001/

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Medicaid to utilize centralized credentialing process for managed care providers this summer

[MM Curator Summary]: LA will implement a single provider enrollment and credentialling system across all MCOs.

 
 

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.

 
 

 
 

First-year implantation phase to begin in July for fee-for-service provider screenings. 

The Mississippi Division of Medicaid plans to implement a centralized credentialing process for managed care providers enrolling in MississippiCAN or Children’s Health Insurance Program (CHIP) coordinated care organizations (CCOs).

This is part of an on-going effort to cut down on red tape and reduce administrative overhead for health care providers.

 
 

Drew Snyder, Director of the Division of Medicaid

“The Division has made it a priority to better understand the challenges voiced by providers and sought to work together toward meaningful change in support of our shared goal of better outcomes for beneficiaries,” said Drew Snyder, executive director. “Streamlining provider credentialing will be a huge step toward focusing on patients instead of processes, and we are grateful to the Legislature and provider community for their partnership on this initiative.”

The implementation will take place over 12 months beginning in July of 2022. Providers will follow the DOM’s current screening process to qualify for Medicaid fee-for-service and MississippiCAN. This will allow for immediate admin relief and will not jeopardize health plan accreditation if approved by the National Committee for Quality Assurance (NCQA).

There are three CCOs administering MississippiCAN: Magnolia Health, UnitedHealthcare Community Plan, and Molina Healthcare. CHIP is administered by Molina Healthcare and UnitedHealthcare Community Plan.

Providers who wish to enroll in those networks are required to complete a separate credentialing process with each plan to verify that they are qualified providers. Additionally, they must undergo re-credentialing every three years to ensure their information is still accurate and up to date.

The traditional “credentialing” process, which is required of all health plans by NCQA is lengthy and often requires the submission of additional documentation and related paperwork. Also, providers must currently credential with multiple entities as described above.

Through bills from the Legislature the DOM is able to simplify the operation by enabling providers to credential through one single avenue that will not only qualify them, but allow them to contract with any CCO. DOM screens providers enrolling in fee-for-service Medicaid but has not been required to credential.

When the implementation period ends on June 30, 2023, providers will have a centralized hub for credentialing in Medicaid-related benefit programs.

 
 

Clipped from: https://yallpolitics.com/2022/04/18/medicaid-to-utilize-centralized-credentialing-process-for-managed-care-providers-this-summer/

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Shreveport area mental health workers sentenced in Medicaid fraud case

[MM Curator Summary]: Two LA mental health providers stole $3.5M from Medicaid by paying members to enroll in their program and submitting false claims for services.

 
 

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.

 
 

Tuesday, two northwest Louisiana healthcare providers were sentenced in connection to healthcare and wire fraud. 

Marty T. Johnson, 59, and Keesha Dinkins, 45,  were sentenced on April 19, after pleading guilty to defrauding the Medicaid Program of $3.5 million. 

Johnson of Shreveport, was sentenced to 60 months in prison, followed by 1 year of supervised release. Dinkins of Bossier City, was sentenced to 24 months in prison, followed by 1 year of supervised release.

In addition, Johnson and Dinkins were ordered to jointly pay restitution in the amount of $3.5 million.

According to information presented to the court, Johnson owned and operated Positive Change Counseling Agency (Positive Change) located in Shreveport from Jan. 2013 to Jan. 2018. Keesha Dinkins was a manager and supervisor at Positive Change.

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Positive Change provided mental health rehabilitation and related services to Medicaid beneficiaries in the Caddo and Bossier Parish areas.

From 2014 to Jan. 2018, Johnson submitted fraudulent claims for mental health rehabilitation and non-emergency transportation services on behalf of Positive Change.

Dinkins knew that Johnson submitted these fraudulent claims which were not performed or rendered. These fraudulent claims resulted in Positive Change receiving payments from Medicaid to which it was not entitled.

Johnson admitted to paying individuals money to enroll with Positive Change, increasing the capacity for Positive Change to bill Medicaid for services that were not rendered.

Johnson instructed employees, and Dinkins supervised those employees, at Positive Change to create false client files to conceal from Medicaid and insurance company auditors and inspectors that it had not performed the services related to its previously submitted claims which had already been reimbursed by Medicaid.

In order to create these false client files, sections from different client documents were physically cut to create inserts that were glued into blank client log templates. These templates with the glued inserts were then photocopied to create the appearance of legitimate documents.

Read:Court approves restitution amounts for Shreveport society swindler victims, some over $3 million

Johnson and Dinkins supervised and knowingly and willfully instructed the employees that were creating these false client files to place the false and fictitious photocopied, cut and pasted, documents into the client files.

The case was investigated by the U.S. Department of Health and Human Services– Office of Inspector General, Louisiana State Attorney General’s Office-Medicaid Fraud Control Unit and Federal Bureau of Investigation. 

Makenzie Boucher is a reporter with the Shreveport Times. Contact her at mboucher@gannett.com.

 
 

Clipped from: https://www.shreveporttimes.com/story/news/local/2022/04/19/shreveport-area-mental-health-workers-sentenced-medicaid-fraud-case/7370079001/

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Missouri struggles to process Medicaid applications

[MM Curator Summary]: Missouri Medicaid eligibility workers are struggling to keep up with the added strain of Medicaid expansion applications.

 
 

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.

 
 

 
 

Sebastián Martínez Valdivia

 
 

KBIA

Filing an application for presumptive eligibility is the starting point in applying for Medicaid coverage.

Missourians who apply for Medicaid are now waiting nearly four months on average to get those applications processed.

Since the state implemented Medicaid expansion in October — opening the door for most Missourians making less than 138% of the federal poverty level — wait times have ballooned.

As of February, Missourians were waiting more than two and a half times the 45 days the federal government says states should take to determine if someone is eligible.

Washington University Professor Timothy McBride spoke with KBIA reporter Sebastián Martínez Valdivia about state’s predicament. McBride studies health policy, and served as chair of the oversight committee for MO HealthNet — Missouri’s Medicaid program — from 2012 until 2019.

Sebastián Martínez Valdivia: How unusual are the wait times Medicaid applicants in Missouri are facing right now?

Timothy McBride: Very unusual. In fact, I’ve been tracking this for probably almost a decade and this is the highest number of days pending I’ve ever seen. There was a time when I was chair of the Medicaid oversight committee when the number of days pending was like 90, and we thought that was pretty high then.

Martínez Valdivia: And what are the biggest factors you think are contributing to the steep increase in wait times?

McBride: Multiple factors unfortunately. I think when I looked at it there were probably 150,000 applicants in about a four month period and a lot of those came from the federal marketplace.

So if people end up applying through the marketplace and then it tells them, ‘Well you actually are eligible for Medicaid.’ Then when the applicants come in there are probably three or four problems that we’re facing at the state level. They’re short-staffed because they have a lot of turnover in the staff, and that’s probably because of pay issues and other issues. Then actually some people have been out a lot because of COVID, so that’s another problem.

Martínez Valdivia: The state says staffing turnover is a big contributor to the difficulties they’re having. You chaired the MO HealthNet oversight committee for many years: is this a new problem for the Department of Social Services?

McBride: I think it’s more acute now than it’s ever been that I’ve seen — you know, I’m not there every day but from what I’ve heard. And I think we’ve historically paid our state employees about the lowest in the country and it just hasn’t grown very much and that problem is going to perpetuate itself. And obviously that was a discussion the legislature was having too after the governor proposed raising pay. So I think it’s always been an issue and I remember hearing about it but I think it’s become more problematic now especially as we come out of the pandemic.

Martínez Valdivia: Are there any immediate changes Missouri could make to speed up the process for applicants?

McBride: Well there are several things that I think people have been proposing for a while. And I think we actually saw this week— every week the state puts out a number of how many people are enrolled in the Medicaid expansion and it went up about 18,000 this week to over 100,000 enrolled now.

So what it appears is happening is that the state is now looking at people in a couple categories including the pregnant women category and the MO Healthnet for families category, and if they are eligible for the expansion, they’re moving them over. Frankly I think that could’ve been done a long time ago, closer to October, and I’m not exactly what took so long.

So in answer to your question, I think there are well-known ways of dealing with this that other states have used that I’m not sure our state is using.
This story was originally published by St. Louis Public Radio’s colleagues at KBIA in Columbia, Missouri.

 
 

Clipped from: https://news.stlpublicradio.org/health-science-environment/2022-04-18/im-not-exactly-sure-what-took-so-long-missouri-struggles-with-medicaid-applications

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Despite opposition, Pennsylvania Medicaid contracts keep unionization language

[MM Curator Summary]: The corrupt inclusion of union-boss graft in Medicaid contracts remains in the latest version of Medicaid health plan 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.

 
 

 
 

(The Center Square) – As Medicaid contracts are worked out to take effect in the summer, draft language remains unchanged that could compel unionization in some Pennsylvania health systems.

As The Center Square previously reported, the HealthChoices Medicaid Managed Care agreements cover the physical health portion of Pennsylvania’s Medicaid contracts, which cover almost 3 million Pennsylvanians and were worth $65 billion over the past five years.

Despite questioning from state senators and representatives who urged the draft language in the contracts to be amended, the Department of Human Services has not modified them. 

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Originally expected to go into effect in July, DHS has delayed them until Aug. 1. “The Department became aware of an issue involving difficulties experienced by at least one managed care organization in its efforts to develop and negotiate inclusion of certain UPMC facilities in its network, which potentially impacts the review of network adequacy requirements,” said Ali Fogarty, communications director of DHS.

However, the language has yet to be finalized, though the original plan was to have contract language finalized by April 1. “The agreements are still in draft form at this time,” Fogarty said.

The contract draft language reads, in part: “The PH-MCO may not include in its network any Provider with a history of one or more work stoppages during the five years immediately preceding the Effective Date of this Agreement, unless the Provider is or becomes a signatory to a valid collective bargaining agreement or is or becomes a signatory to a labor peace agreement with any labor organization that informs the Provider that it is seeking to represent the Provider’s employees at any site in the PH-MCO’s network that delivers services to HealthChoices enrollees.”

The agreement “is intended to prevent service disruptions to the PH-MCO’s members caused by employee unrest or dissatisfaction,” it reads. 

That has not sat well with the Hospital and Healthsystem Association of Pennsylvania, which has sent multiple letters to DHS opposing the language.

“Pennsylvania’s hospital community is very concerned about proposed language in upcoming Medicaid managed care contracts that, based on recently updated estimates, could jeopardize access to health care for hundreds of thousands of Pennsylvanians,” said Liam Migdail, director of media relations for HAP. “If enacted, this proposal would preclude a dozen or more hospitals from caring for patients, including some that are the only hospitals in their rural communities and others that offer specialized care for women, children, and people with cancer.”

 
 

Clipped from: https://www.wfmz.com/news/state/despite-opposition-pennsylvania-medicaid-contracts-keep-unionization-language/article_a7d36912-5a01-572c-8519-2a8d0e51566a.html

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Nearly 2,000 providers to receive $503M in Medicaid grants

[MM Curator Summary]: The FL HCBS ARPA money is finally moving to providers.

 
 

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.

 
 

 
 

Florida Medicaid officials are distributing nearly $503 million in enhanced payments to 1,945 providers that render community- and home-based services to the poor, elderly and disabled, the administration of Gov. Ron DeSantis announced Tuesday.

That’s about $180 million less than what the Agency for Health Care Administration initially said would be made available last year when the agency announced the availability of the funds and encouraged home- and community-based service providers to apply for the supplemental payments. The funding was made possible by the American Rescue Plan, pushed by President Joe Biden.

The state did not offer a list of the providers that will be receiving the money. Instead, the state is sending emails to the providers notifying them of whether their requests were accepted and to “provide instructions on next steps.”

AHCA told Florida Politics Tuesday the state is reopening the window of opportunity for providers that use 1099 staff to submit applications for the funds. Those providers will have until May 20 to submit a grant application to the state. The $180 million will be used to help fund those new grant applications.

It will also be used to fund $12 million in delayed egress grants. Those grant awards were not announced Tuesday.

 
 

If necessary, some of the $180 million can also be used to adjust grant applications that were erroneously rejected or wrongly calculated, AHCA said.

“From the beginning of his administration, Gov. DeSantis has led the charge amongst the nation’s Governors in putting Florida’s seniors and most vulnerable first,” AHCA Secretary Simone Marstiller said in a prepared release.

“The agency is pleased to award this enhanced funding to Florida’s home- and community-based services providers who are working hard to address record increases in operational costs and challenges in recruiting and retaining staff.”

Florida’s home- and community-based Medicaid providers have been waiting for weeks for word about the grant awards. The state on Feb. 15 told the federal government it wanted to have the money distributed by the end of March.

AHCA Communications Director Brock Juarez defended the agency’s work to get the money distributed.

 
 

“From the onset of the (home and community based) enhanced funding program, AHCA has been at the front of states in applying and administering this funding to mitigate the impacts of inflation and workforce capacity to support HCBS providers, who provide care for some of the most vulnerable Floridians,” Juarez said in a statement to Florida Politics. “We are proud of the hard work and dedication of our team to process over 2,000 applications and award over a half billion grant funding in only two months’ time.”

The agency announced late last year it would award $1.2 billion in supplemental payments in two rounds. More than $680 million was made available during the first round of funding, and the state accepted applications between Dec. 17, 2021, and Feb. 14, 2022. The money was divided into three silos: $405 million in grants for one-time provider stipends, $266.6 million for retaining employees and recruiting new ones, and $12 million for delayed egresses.

Ninety three percent of the approved grant applications requested funds from more than one silo.

Juarez said the money would be first distributed to providers who worked with Medicaid iBudget Waiver clients, followed by those who work with Medicaid managed long-term care clients.

The iBudget waiver program, administered by the Agency for Persons with Disabilities (APD), provides people with intellectual and developmental disabilities access to services that keeps them out of institutions and living in the community.

“The foundation of this funding plan builds on APD’s dedication to ensuring that vulnerable Floridians have the resources they need to thrive in their communities,” APD Secretary Barbara Palmer said in a prepared release. “These funds will make a huge difference to attract qualified applicants to serve our vulnerable customers.”

The state will rely on the contracted Medicaid managed long-term care plans to distribute the enhanced payment to the home- and community-based services providers they contract with. The Medicaid managed long-term care program allows people who qualify for nursing home placement to forgo institutional care and choose to receive home- and community-based services instead.

Clipped from: https://floridapolitics.com/archives/517612-nearly-2000-providers-to-receive-503m-in-medicaid-grants/

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New York audit finds nearly $1B in Medicaid billing errors

[MM Curator Summary]: Th NY Comptroller continues to find extensive improper Medicaid payments in the Medicaid program year after year.

 
 

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’s Medicaid program incorrectly paid out nearly $1 billion to providers over a four year period, according to two audits released Tuesday by state Comptroller Tom DiNapoli’s office. 

The audits found the improper payments were made for services that included ordering, prescribing, referring and attending providers who are no longer enrolled in the Medicaid program at the time of the service. 

At the same time, improper payments of $5.8 million were used for services for providers who were excluded from participating in the Medicaid program due to previous improper behavior or wrongdoing. Changes to the program known as eMedNY were made in February 2018 that had led to a notable drop in the number of improper payments, the audit found. 

Nevertheless, from March 2018 to December 2019, the comptroller’s office still found $45.6 million in payments for more than 135,000 services to providers who are not eligible. 

“Medicaid is a critically important program, but its payment system is rife with errors,” DiNapoli said. “My auditors found the system was allowing payments on claims involving providers who were not certified to treat Medicaid patients. This not only costs taxpayers, but also allows providers who should be excluded, and may be unqualified, to treat patients. DOH must improve its efforts to fix the shortcomings with its billing system.”

The comptroller’s office recommended the state Department of Health review payments for Medicaid claims involving inactive providers, strengthen controls to prevent improper payments and update guidelines to clarifying billing rules. 

 
 

Clipped from: https://spectrumlocalnews.com/nys/central-ny/ny-state-of-politics/2022/04/19/comptroller-audit-finds-nearly–1b-in-medicaid-billing-errors

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Providers still waiting for state to deliver $1.2B in supplemental Medicaid funds

[MM Curator Summary]: Zero dollars and zero cents of the $1.2B Florida took from ARPA have been distributed to providers more than 6 months months after the funds made it to state coffers.

 
 

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.

 
 

 
 

In an effort to bolster the state’s home- and community-based services network, the Gov. Ron DeSantis administration late last summer agreed to tap into $1.2 billion in additional federal Medicaid funds.

More than six months later, the state hasn’t distributed any of the supplemental funds and providers don’t know when to expect the payments. They also don’t know how much to expect because the state did not finalize the distribution formula it was going to use to disburse the funds.

Attain Inc. has taken out two small business loans since September when the state announced it received approval from the federal government to use the funds, said Craig Cook, executive director of the not-for-profit agency that has been providing residential services to people with disabilities in central Florida since 1988.

The loan money, Cook said, is being used to cover deficit spending, the result of years of stagnant Medicaid reimbursement rates and a tight long-term care labor market that was made worse by the COVID-19 pandemic.

“We were given hope,” Cook said of the supplemental Medicaid payments. “But now, it’s like there’s no help at this point, because nothing is being realized.”

 
 

Cook, and many other providers like him, thought that the state would have distributed the supplemental payments by now. And according to documents submitted to the federal government, the state intended to have the payments distributed by winter 2022.

Agency for Health Care Administration Communications Director Brock Suarez did not comment on why the funds were delayed.

Cook’s application for funds was one of more than 2,400 received by the agency before the Feb. 14 deadline.

The agency announced late last year it would award the supplemental payments in two rounds. More than $680 million was made available during the first round of funding and the state would accept applications between Dec. 17, 2021 and Feb. 14, 2022.

The money was divided into three silos: $405 million in grants for provider stipends, $266.6 million for retaining employees and recruiting new ones, and $12 million for delayed egresses.

 
 

Providers could apply for funds from more than one silo.

And they did.

Of the more than 2,400 applications received, 89% of them were for one-time stipends and 82% of the applications were for retention funds. That’s according to Kristin Sokoloski, a Medicaid program coordination administrator.

Sokoloski told members of a Medicaid medical advisory committee that assisted living facilities, home- and community-based service providers, home health agencies and case management agencies qualified for supplemental Medicaid funds during the first round of funding.

The majority of the applications received, 70%, were submitted by home- and community-based providers. Of those providers, 70% worked with people enrolled in the Medicaid iBudget Waiver program, according to Sokoloski’s presentation to the committee.

Jim DeBeaugrine is the former director of the state Agency for Persons with Disabilities and currently is a lobbyist for a spate of clients that provide services to people with intellectual and developmental disabilities. That includes The ARC of Florida.

“They are definitely very interested in these funds and a lot of these guys are barely hanging on,” DeBeaugrine said. “The quicker this can get out there, the better.”

The DeSantis administration moved last summer to take advantage of a 10% bump in federal Medicaid dollars available under the American Rescue Plan Act.

Most Florida Medicaid patients who receive home- and community-based services are either enrolled in the Medicaid managed long-term care program or the Medicaid iBudget program.

The former is for frail and elderly individuals who qualify for nursing home placement but choose to receive assistance with daily living activities, such as eating and dressing, that enable them to continue to live in their homes or another non-institutional setting.

Similarly, the Medicaid iBudget Waiver program allows adults with intellectual and developmental disabilities to tap into the home- and community-based services they require to continue living outside of an institution and in their family home or a group home.

Tyler Sununu is the president and CEO of the Florida Association of Rehabilitation Facilities, an association that represents facilities that treat people with intellectual and developmental disabilities.

“Providers are asking me every day for an update,” Sununu said about the additional payments. “The bottom line is providers really need the money and I’m very hopeful that if not this week, next week we’ll see some of that.”

The agency is supposed to announce a second round of funding opportunities sometime this month.

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Clipped from: https://floridapolitics.com/archives/516083-providers-still-waiting-for-state-to-deliver-1-2b-in-supplemental-medicaid-funds/