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Archive Monthly Archives: February 2017

Medicaid Industry Who’s Who Series: Jennifer Sweet

Join Jennifer Sweet April 17-18 in Chicago to hear from policy insiders, MCO leaders and state officials who will provide a clearer picture of the future of Medicaid expansion and financial alignment, as well as proposed Medicaid regulations! Register using code HMP139 for a 15% discount at

Medicaid Who’s Who: Jennifer Sweet – Medicaid Segment Lead for Florida Blue

 1. What segment of the industry are you currently involved?

 A: I am on the payer & managed care side of the industry.  I am working in Florida where the Medicaid population is largely managed by MCOs.

 2. What is your current position and with what organization?

A: I am the Medicaid Segment Lead for Florida Blue. 

 3. How many years have you been in the Medicaid industry?

A:  For about a decade, and before that, in commercial health insurance.

 4. What is your focus/passion? (Industry related or not)

A:  In terms of work, I am committed to doing things “right” for this population – and that entails everything from delivery of quality and appropriate services to the people who need these services to being an effective steward of taxpayer funds and a good partner to our state Agency.  We are all on the same side, serving our communities, is how I see it.  Personally, outside of work, I love to travel and experience other cultures, languages and architecture.

 5. What is the top item on your “bucket list?”

A: I work with a not-for-profit, the Lyceum Fellowship, that awards travel grants to talented students of architecture.  My goal is to ensure this organization is funded and managed such that it survives long after I do.

 6. What do you enjoy doing most with your personal time?

A:  I appreciate finding spaces of quiet down time on the weekend to simply read, walk my dog, hang with family and friends.  

 7. Who is your favorite historical figure and why?

 A:  I enjoy reading both history and biography so picking a favorite is hard.  I enjoy learning what motivated the person who has a significant accomplishment, and where he or she drew the strength to fight for the accomplishment. Abraham Lincoln is a prime example.  But brave, grand acts are interesting to read about in much lesser known characters as well.   It’s also interesting to get a glimpse of how others think and frame the questions of their time.  Ruth Bader Ginsburg and Oprah Winfrey come to mind as I say that, or Margaret Thatcher.

 8. What is your favorite junk food?

A:  Popcorn, specifically, hot air popped with butter and salt.  Always has been my favorite, I was never a chips-cheetos-fritos kind of kid. 

 9. Of what accomplishment are you most proud?

A:  I am very proud of my son and my family but I don’t consider them an “accomplishment” per se.  So I’d have to say that there isn’t a single grand accomplishment but rather, all the wins along the way – whether in education, business, hobbies, love – they all add up to a core accomplishment that is my life.  I am happy with it.

 10. For what one thing do you wish you could get a mulligan?

A:  I don’t want a mulligan so much as a repeat performance of some great moments in my life.  The times when things fell short, well, they are what they are and they are behind me now.

 11. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months? 

A:  Knowing that the changes ahead (at both state and federal levels) are likely to be significant & fundamental, any list has to include effectively planning the response to those changes.  But in the meantime, I’d say: 

  1. Align payers and providers through appropriate contracting that establishes partnerships as a means of improving not only the lives our members/patients and our respective businesses, but to contribute to  improvements in the very fractured US health care marketplace.   
  1. Improve the whole world of data in Medicaid – as in: capturing more accurately the services we deliver, communicating this effectively to others (e.g., providers, the state Agency), and advancing the way we use this data in search of more effective, efficient management of care. 
  1. Make space to be innovative, to find solutions that move us forward – not easy to do in the din of everyday operations and life.

Clay’s Weekly Medicaid RoundUp: Week of February 20th, 2017

Soundtrack for today’s RoundUp pessimist readers-

Or you can click the one for optimist readers –


THE WHEAT STATE TILTS AT WINDMILLS- Either KS and ME know something we don’t, or these 2 states are about to get approval for Medicaid expansion in the era of Trump. ME got it on the ballot and KS reps just passed it in their house. Or maybe lefty reps in both states are play-acting to look good for their base since Dems in generally are licking wounds right now? You decide. News and Weather at 10.


HEART OF DIXIE WANTS CAID FOR CONS- Err, sorry I meant to say “justice-involved.” Please don’t take away my snowflake card. Senator Cam Ward wants Alabama to get some help from the federalis to cover inmate costs. If his bill goes through, the feds (that translates to “taxpayers in other states”) will pay 70% of the costs of healthcare for Bama’s bad guys.


CONTINUED CHAOS IN UNHINGED WHITE HOUSE WITH DARK VISION OF AMERICA. DOOM! DOOM! DOOM! RUSSIANS! RESIST! Actually, yet another logical, calculated appointment was made to President Trump’s team this week. Brian Blase just joined the staff. Blase is a PhD economist who spent time as a Senate staffer and has been very open about his criticism of current Medicaid financing shenanigans. Couple this with the appointment of Price to DHS and Veerma to CMS- Mr. Trump is not joking about transforming Caid. The Resistance will have to do better than misbehaving at town halls and worshipping Michael Moore if they want to effectively shape what’s coming.


BEAVER STATE SEES DROP IN ENROLLMENT– There’s been about an 11% drop in Oregon Caid enrollment comparing Jan 17 to Mar 16. This translates into 133,000 less managed care members, which = 133k x 12 x the average cap rate less money for the MCOs (CCOs) in Oregon (I do fancy Medicaid math, you should sign a consulting agreement and pay me to do fancy Medicaid math for you. I also put most of my internal thought processes in parentheses [rarely in brackets] {and never in whatever these things are}). That’s a lot less cash the MCOs (CCOs) have to operate and will probably lead to some sort of horse-trading required come rate-setting time.


MOLINA POSTS NY CAID LOSS; RECENT SIGNALS OF EXITING EXCHANGES- Revenues for Molina in NY dropped $185M YOY, resulting in an overall $192M Q4 loss. The main culprit? Having to pay $322M into a risk adjustment pool that then got redistributed to other MCOs who showed higher risk memberships. Molina has also recently begun socializing the idea of it pulling an Aetna and exiting the exchanges.


XEROX (OLD ACS) ASKS JUDGE TO LIMIT THE PAIN IN THE LONESTAR STATE- The flailing MMIS giant has alleged that the state is using “a web of lawsuits” to jack up potential settlements related to that whole debacle over prior auth for orthodontics services for TX Medicaid bennies. Xerox wants to be able to designate the dentists involved as responsible 3rd parties. TX wants to be able to sue Xerox AND the dentists separately. The suit currently rings up at about $1B in potential payouts.



FARRIS’S FANTASTIC FRAUD FOLLIES– None this week dear readers. I hear you collectively, depressively sighing. But remember- I gave you an entire Roundup of Fraud Follies like 2 weeks ago. Remember that. Hold it close.


That’s it for this week. As always, please send me a note with your thoughts to or give me a buzz at 919.727.9231. Get outside (its spring. You know its spring.) and keep running the race (you know who you are).


FULL, FREE newsletter: . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Uba ya aiko Ɗan ya ceci duniya

Menges Group 5 Slides Series for Jan and Feb 2017

The Menges Group puts out these great analyses and insights each month. And is kind enough to let us repost them for the MM audience. Check out to learn more about the work they do. 

The January edition tabulates the distribution of Medicaid pharmacy costs by unit price cohort.  Explosive growth in the share of Medicaid prescriptions among drugs costing more than $1,000 per prescription (pre-rebate) continues to occur.  These drugs now represent 40% of all Medicaid pre-rebate prescription drug expenditures.

The February edition tabulates overall health care expenditures from 2006-2016, and shows the progression of Medicaid, Medicare, and private health spending.  A key observation from these tabulations is that health costs haven’t grown all that rapidly across the past decade – annual per capita cost increases have averaged 3.7% for the entire US population, 2.3% in Medicare, 3.2% in Medicaid, and 4.0% in the rest of the population.


Health Expenditures Progression 2006 – 2016 Feb. 2017


Price Per Script Categories Jan. 2017 (1)

Medicaid Industry Who’s Who Series – Dr. James Bush

Dr. James Bush is the featured panelist for the upcoming Wyoming State Medicaid Spotlight Webinar on March 6th. RESERVE your seat today!


Medicaid Who’s Who: Dr. James Hall – Chief Medical Officer, Wyoming Medicaid

  1. What is your current position and with what organization?

A: Wyoming Medicaid Medical Director

  2. How many years have you been in the Medicaid industry?

A:  10 years

  3. What is your focus/passion? (Industry related or not)

A:  Quality improvement

  4. What is the top item on your “bucket list?”

A: A smooth transition to high-value care and revitalized primary care.

  5. What do you enjoy doing most with your personal time?

A:  Travel, hunting and music.

  6. Who is your favorite historical figure and why?

 A: Marcus Tullius Cicero. Defender of the Roman Republic.

  7. What is your favorite junk food?

A:  Pizza

  8. Of what accomplishment are you most proud?

A: 37 years of marriage and two great children.

  9. For what one thing do you wish you could get a mulligan?

A: Some ill-chosen business partners.

  10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months? 

A:  What will stay or go from the ACA, the transition to High value high quality care, and the evolution of HIE. ​


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Clay’s Weekly Medicaid RoundUp: Week of February 6th, 2017

Soundtrack for today’s RoundUp pessimist readers-

Or you can click the Special Valentine’s Day treat for optimist readers –


It’s been a while my dearest readers. As is our custom when returning from hiatus, let’s begin with the normal ending segment…


FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award.  Maria Navarro and Judith Bench of Orlando are charged with using their special needs school to bill 21,000 bogus Medicaid therapy claims. They billed for 8 hours a day but only had staff to provide 2. Taxpayer tab – $4.5M. Pedro Garcia of Mission, TX was charged this week with submitting Medicaid claims for dead people – to the tune of $300k. John Holland of Miami was CEO of Portneuf Medical Center when he (allegedly) took bribes that facilitated $12M of Medicaid fraud. He plead not guilty this week. Michael Johnston of Broadheadsville, PA got sentenced for pilfering $100k from Medicaid using bogus mental health services claims. Mr. Johnston took the cash and used it cover trips to Jamaica. Stephen Monaco (awesome name), a podiatrist from Haverton, PA was sentenced this week for stealing $4.9M from Medicaid, Medicare and other payers. Dr. Monaco would barter opioids with patients in exchange for them letting him shoot painful (but unnecessary) injections into their feet. Eduard Zavalunov of NYC became the 9th fraudster to plead guilty in a multi-clinic racket that bribed Medicare and Medicaid bennies (with cash) to undergo unnecessary tests. Taxpayer tab – $70M. Shalonda Suggs of Oklahoma City pled guilty this week to a $200k mental health services not provided scheme. Julia Faigel of Boston, MA was ordered to pay $475k for Medicaid dental fraud. She had TWENTY ONE corporations she used to rob the taxpayers. Robert Windsor of Cumming, GA pled guilty this week of bilking GA Medicaid, KY Medicaid, Tricare and FEHBP (the healthcare federal employees get) for more than $20M. His gig? Medically unnecessary balance tests, electromyography (whatever the heck that is) and qualitative drug screens. IPC – a hospital staffing firm that provides doc labor, also goes by Team Health if you are googling for it- will cough up $60M for defrauding Medicaid and Medicare via upcoding. Dr. Oughatiyan was the whistleblower and he will get $11.4M. Bernard Greenspan of Newark, NJ got $200k in bribes for his role in a $200M fraud scheme. He’s pleading innocent (he’s also 80 years old), but 2 dozen other docs have pled out on this scheme which involved Biodiagnostic Lab Services bribing docs for referalls to Medicare and Medicaid. And now, drum roll (we have a lot of contestants this week!)… Mr. Windsor you win this week’s award for your tenacity and not settling for ripping off just one Medicaid program. Indeed – stealing from both GA and KY sets you apart. I hope you stashed some cigarette money someplace, so you can barter in the slammer.


Sadly, I was able to fill an entire Roundup with fraud follies (with a total of about $384M stolen by my rough count). I could do this each and every week (but that would be boring). And I left out several big ones this week, too. Nothing to see here, move along. Regardless of whether we repeal, replace or repair there will always be this wonderful gravy train for fraudsters. As I pay my taxes in the next month or so, I know that makes me feel good. How about you?


That’s it for this week. As always, please send me a note with your thoughts to or give me a buzz at 919.727.9231. Get outside (I swear we never have winter anymore here in AL. Must be global warming, or maybe the Russians?) and keep running the race (you know who you are).


FULL, FREE newsletter: . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Papa a voye Pitit la pou konsève pou mond lan