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Clay’s Weekly Medicaid RoundUp: Week of February 11th, 2019

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2X0xroM

For optimist readers- http://bit.ly/2X0qqEz

NEW ONLINE TRAINING COURSE IS OUTWant to understand the opioid crisis? Our newest online course will help. Check it out here- http://bit.ly/2WEL3G4

IDAHO DECIDES TO MEASURE IMPACT OF EXPANSION- Medicaid expansion is getting its very own budget item so it can be tracked precisely. I know about 30 states who wished they would have thought of this.

ALASKA BACKLOG OF APPLICATIONS GOING DOWN BUT STILL A PROBLEM- The Frontier State is struggling to scale its Medicaid program after expansion nearly doubled its rolls.

 MEDICAID ROLLS DECREASING IN SOME STATES; LEFTIES FORGET THE “BUT MEDICAID IS COUNTERCYCLICAL TO THE ECONOMY” LINE- To admit the economy is improving would admit The Duly Elected President of the United States of America (DEPOTUS) just might be helping rescue us from the disastrous economy he inherited. Such an admission is impossible for most in our Medicaid world. Other theories: re-enrollment apps are too many pages long (TN has 47 pages to fill out to get back on the rolls) or bennies re-applying have to wait on the phone lines too long (MO). Overall, Medicaid enrollment declined about 1.5% nationally last year. Which really isn’t that much when you realize it basically doubled in an 8-year period under ACA. So, class- Medicaid grew 100% in 8 years, then it took a 1.5% step back in the last year. (At this rate it would be 2120 before we got back to pre-ACA bennie levels). Let’s all FREAK OUT!!!! ORANGE MAN BAD! I’ll leave you with this quote from a TN Medicaid official – ““Tennessee is experiencing a state economy that continues to increase at what appears to be near-historic rates.”

 MICHIGAN WORK REQUIREMENTS BATTLE RAGES ON- The Good Guvn’r (the new one- Whitmer) is looking to undo the work requirements plans already approved by CMS. She has a new report with bigger numbers on how many will lose coverage if they don’t comply with the requirements. Pro tip for those wanting to undo work requirements already approved by elected (that word is put there to remind you that about 50% of voters disagree with you) officials: looks like you just need to know the right consulting firm to get the numbers you need to justify the reversal.

 

VOLUNTEER STATE STEPS FORWARD FOR BLOCK GRANTS- TN state reps filed 2 bills this week (1 in the house, 1 in the senate) to require the Medicaid agency to request a waiver from CMS to convert to a block grant program. 1st shots fired. For history buffs wanting to chase a rabbit trail right this moment instead of doing whatever you are supposed to be doing at work, read the wiki page about an American hero involved in the first shots fired during the American Revolution- Crispus Attucks. For all you whippersnappers drinking the green kool-aid, the American Revolution was how this unique, wonderful country got started and began the beautiful, unique, one-of-a-kind story that is America. Thank you, Crispus, for your role in making this place awesome.

 

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. Manuel Barit of WV plead guilty to stealing $200k. His crime? Submitting claims for treating bennies when he was actually out of the country. The scam went on for six years. Ryan Sheridan of Austintown Township (Ohio) was charged with stealing $31M with bogus substance abuse treatment claims (DBA “Braking Point Recovery Center”). He and his buds operated recovery centers all over town. Lillian Richardson and Bridgett Burrel of Minnesota got convicted this week of stealing $7.7M in Medicaid bucks using five (count em’, five!) home care agencies they set up under the names of different family members. They submitted lots of bogus claims for helping disabled Medicaid members with daily tasks. Fun Fact- Richardson was convicted on a different Medicaid fraud in 2012 but pinky-swore to not do it again. Guess pinky swears are not what they used to be in 4th grade.  Mr. Sheridan – you win. $31M is a decent chunk of change, even for Medicaid fraud.

Need even more Medicaid fraud stories? – You can get your fix in the FWA Curator archives.

Want to read the articles summarized here, highlighted for your reading pleasure? Check out the News Curator archives.

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (or stay inside and order seeds – its that time again) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: Rama dikirim Putra ka ngahemat dunya.

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Clay’s Weekly Medicaid RoundUp: Week of January 14th, 2019

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2VYimnr

For optimist readers- http://bit.ly/2W235C3

ABOUT THAT WHOLE MEDICAID TRANSFORMATION IN NY THING. YEAH, LET’S STOP DOING THAT- After years of major overhaul efforts to transform its Medicaid program, Cuomo just pressed pause on the key device real driving change. For 8 years, NY has capped Medicaid spending to be within a 10-year rolling average of medical inflation. In this next budget, the Good Guvn’r decided to give Big Med (primarly hospitals) a pass and allow Medicaid spending to exceed the cap (3.1% is the cap; Cuomo is authorizing 3.6%). Why, you ask? As a pre-emptive strike (in his view) to shore up against federal changes coming to Medicaid. What federal changes? Reductions in DSH that were started when ACA passed (in 2010), but Big Med has been able to get delayed year after year.  Lefties, rejoice (and don’t forget to vote for him when he runs for Pres in 2020). Righties, observe yet another tax and spend Dem refusing to reform their ways (cuz, you know, they’re the good guys and your’e evil if you doubt that). Total Medicaid budget now that NY Medicaid is on a cheat-day? $19.6B (which is roughly the GDP of Botswana, and more than the GDP of 118 countries. For freakin’ Medicaid in NY, people).

HOW WAS YOUR EXPERIENCE? MA TO POLL PATIENTS- Medicaid members in The Old Colony State will be asked to rate providers and plans for the first time. Results will be made public in 2020. From what I can tell this is basically a CAHPs-type survey. Results will also likely be used for value-based care payments.

SHAKEUP IN ARKANSAS NEMT- For readers keeping tabs on the Medicaid transportation scene: Southeastrans is picking up more regions as MTM will exit. Handover starts Feb 1.

JUST WHY ARE HOSPITALS IN VIRIGINIA SO EAGER TO BE TAXED? Why do hospitals exist? To help people AND to make money. When asked why they exist, what is the answer? “To help people.” They conveniently leave out that second part. When you put it back in, it makes a little more sense why VA hospitals are eagerly paying a “tax” to help fund the recent explosion (expansion) in Medicaid spending. State reps are getting their first taste of the “surprise” cost over-runs in the expansion they approved last year. This week new adjustments to expansion costs show at least $85M more than what they were told when they voted “yes”. Hospitals, those noble creatures they are, are running full press coverage highlighting how they are so, so happy to pay a tax to help fund expansion. Long time readers remember that Medicaid provider taxes are often a total sham described thusly: we pass the hat to hospitals, who all chip in money. We then beam up the hat to planet CMS, who puts in 6x more money (or 7x or whatever your fmap is), and then sends it back down. The state gets more cash, and so do the hospitals.

PALMETTO STATE JOINS RANKS OF WORK REQUIREMENTS REFORMERS- Looks like another 1115 app will be hitting the halls of 7500 Security Blvd in Balto soon (where planet CMS is). South Carolina is doing town halls on a work requirement proposal as of this week.

IMPLEMENTING BALLOTED (IS THAT A WORD?) EXPANSION PROVING TO BE HARDER THAN CHECKING A BOX ON VOTER CARD- Utah lawmakers are trying to figure out how to pay for the expansion approved by voters in November. There are 2 issues in play: 1) how to keep the limited expansion already in place going while applying for CMS to approve full / “standard” expansion we’ve all come to know and love; and 2) how to come up with numbers during the current budget cycle that at least try to pretend there’s a way the state can pay for it. A sales tax increase is projected to come up about $45M short in the next few years.

HOSPITALS AFRAID SETTING LIMITS ON MEDICAID SPENDING COULD HURT THEIR REVENUES- See earlier entry above about why hospitals exist. As CMS suggests states may find approvals for block grant waiver apps if they only ask, hospitals are going nuts in the press. Sky is falling, cutting spending will kill everyone- you know the dril by now. There are increasingly insightful quotes coming from Verma on this. Here’s a good lil’ nugget: “We also believe that only when states are held accountable to a defined budget can the federal government finally end our practice of micromanaging every administrative process.“ Hear, here!

IN A RELATED NOTE, GA WANTS MORE FREEDOM FROM FEDERALI MICROMANAGING FOR ITS CITIZENS’ HEALTHCARE NEEDS- The Good Guvn’r Kemp (who recently barely beat romance novelist Stacy Abrams) announced a $1M project to explore a waiver with CMS that would give the state more flexibility with its use of federal Medicaid dollars. No other details than that. You get to fill in the blanks (most fill them in with block grants based on early analysis). In a somewhat related news item, GA teachers will be getting a $3k raise this year.

PASSPORT STRUGGLING WITH NEW NORMAL IN KY- For those of you watching this MCO market, Passport has been unscuccessful in getting the state to budge on recent cap rate cuts that hit Passport particularly hard. Short version – state changed up regions and rates in a way that Passport got hammered. And Passport’s whole business is Medicaid. More to come.

CANARY IN COAL MINE IN AR? We all like to think we are special and unique. Medicaid programs are no different (see what I did there?). Arkansas cooked up yet another version of the “here’s how we’ll transition legacy behavioral health providers to a capitated rate” idea a few years back. (It’s an acronym that spells PASSE; did no one look that up in French?) Like most of these inititaives, year 1 starts out all nice and you get basically extra cash to play along and maybe do a little more case management than before. In year 2 you are expected to manage medical services, pay claims, etc (depending on the state). Well, ForeverCare sees the writing on the wall (or is chickening out if you listen to state officials) and is dropping out. They say they will come back in if the Phase II implementation date is moved to July 1. It has already slid from Jan 1 to March 1.

 

READY FOR MEDICAID INNOVATIONS 2019- I will be there again this year (my 9th time), chairing one of the very best Medicaid events you can go to. Also, its sunny Florida in February (I’m looking at you, Michigan). If you decide to go, let me know and we can meet up. Check it out here – https://www.medicaidinnovations.com/

 

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- not so fast fraud junkies. No where near enough space this week. You can get your fix in the FWA Curator archives though.

Want all the highlighted news items from this week? Check it out here-Medicaid News Curator Volume 5

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (buy or chop some firewood) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: Baba alimtuma Mwana kuokoa ulimwengu.

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Clay’s Weekly Medicaid RoundUp: Week of December 31st, 2018

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2Qnzwqf

 

For optimist readers- http://bit.ly/2QovzSr

 

READY FOR MEDICAID INNOVATIONS 2019- I will be there again this year (my 9th time), chairing one of the very best Medicaid events you can go to. Also, its sunny Florida in February (I’m looking at you, Michigan). If you decide to go, let me know and we can meet up. Check it out here – https://www.medicaidinnovations.com/

 

PREVIEW OF MONDAY’S MEDICAID NEWS SHOW- We will cover the Texas ruling, state budgets and about a million other things. Not signed up yet? Sign up here for free-

http://bit.ly/2H8xAz1

 

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. Since we’re punting news to the Monday show, lets do a butt-ton of fraud this week. Darrel Bryant and Gifty Kusi of Hillard, Ohio were convicted of stealing $3M from Medicaid for bogus drug cream claims. They were assisted by Jornell Rivera, who is a “doctor” listed as a co-conspirator in the case. Abdi Ali Gure of Bloomington, MN was charged for stealing $260k with a services-not-provided scheme. Laird Richmond and Jason Lowery of Seattle, WA were ordered to pay back $928k they stole by not paying employees the full “sleeping” rate. In WA, if you require staff to stay overnight in a residential facility, you have to pay them a certain rate while they sleep. These 2 yahoos billed the state for the full rate but didn’t pass it onto the staff. Christiana Care (Delaware’s largest hospital system) is back on the radar for yet another fraud scheme. A few years ago the health system settled for $3.3M with the state to make allegations related to shady billing practices in its neonate unit go away.  Now an auditor has surfaced new issues in the past few weeks. Lisa Raymond and Robert Maglicic of Florence, SC were charged with stealing $2M from Medicaid for behavioral health services not provided. Toshirea Jackson of Bridgeport, CT was ordered to pay back the $2.5M she stole using her 2 social services businesses. Seems Mrs. Jackson was stealing the Medicaid IDs of people she was counseling for substance abuse, and then using them to submit false claims. Luis Omar Vargas of Roselle, NJ was convicted for stealing $2M with a dental patient kickback scheme. He paid patients $25 to do a visit (wish I got paid for visits- doesn’t it normally work the other way around? Are we to believe the patients innocent in this? Were they tried? If not, why not? $2M!!!), and then billed Medicaid for boucoup more on bogus claims. Haytham “Tom” Fakih of Deerborn, MI stole $1.2M from Medicaid and Medicare (not eligible for this week’s award, Tom) by billing for expensive meds to dead patients. Mobolaji Stewart of Maryland stole $434k from D.C. Medicaid with bogus personal care aide claims. She even billed for more than 24 hours in a day (now that’s commitment). Fly clear across the country to Alaska to meet Sirje Kulakevich, who stole “more than $50,000” as a personal care aide in the The Last Frontier. Margaret Fisher of the Music City fled to North Dakota, but her $1M Care and Caid behavioral health fraud caught up with her this week. She (and her staff at her direction) forged signatures on counseling session documentation. George Louis Moreno of McAllen, TX plead guilty to a $1.5M DME fraud this week. His crime, lots and lots of bogus claims for incontinence supplies. Messieurs Bryant and Kusi, you win! Something about the $3M worth of cream spoke to me. Taxpayers, you lost at least $18M in that last paragraph ($36,437 per word).

 

Check out the Fraud Curator for the original articles for the adventures above. Also lots of member fraud nuggets in it, too.

Medicaid FWA Curator- Vol 5

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (if it ever stops raining) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: Padar Pisarro firistod, to in ki dunjoro naçot dihad.

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2018 Year in Review: You Can’t Put a Bow On It (Or Maybe You Can)

And now its that time of year we do the annual Mostly Medicaid (really Clay’s) Year in Review. For past reviews, visit here and here. If this is your first Year in Review with us, fair warning: it’s the one time I get all sappy. Provides a nice contrast to the cynicism and sarcasm you probably read the RoundUp for.[1]

 

You will need tissues.

 

Winter is a time for thinking.

A certain type of thinking, really. Reflection, introspection. All the eckshuns.

Spring is for hope and eagerness. Summer is for playing (and if you are a teenager in love it is a time of rhapsody and skirting curfews). Fall is for slowing down a bit, and breathing in the fresher, cooler air. Watching the oranges and reds and yellows on the trees.

But winter is a time for thinking.

And so I think, sitting in front of my fireplace. Warming my toes, my thoughts and-  I hope – my heart. For just as winter brings cold outside, it also brings cold to many hearts.

Hot soup can help. Or a game of cards with an old friend.

 

***

 

Sometimes we do things not knowing exactly why, but trusting they are important and will be valuable at some point in the future.

About 20 years ago, I started saving every single card people gave me and put them in a box. After a year or so, I outgrew that box. And now I am about to outgrow a large plastic tub.

Being a strict minimalist, cards are the one thing I let myself pack-rat.

I can remember the exact conversation that started this habit. A friend of mine and I both loved the same band (the Weakerthans). In their song Left and Leaving[2], are the lyrics:

 

Duct-tape and soldered wires
New words for old desires
And every birthday card I threw away

I wait in 4/4 time
Count yellow highway lines
That you’re relying on to lead you home

 

When discussing this song, my friend was struck by this particular line about throwing away birthday cards. They said something to this effect: “You know, every time someone sends you a card, they were thinking of you. Thinking of you enough to spend $2.99[3], write something about you specifically from their heart, and place it in the mail or hand it to you. We really shouldn’t throw those cards away.”

And from that moment on I didn’t.

I get rid of most things. I hate clutter. I don’t hold onto anything else for sentimental reasons. But – I have a box of birthday cards, get well cards, letters, graduation notes, thank you notes,[4] and myriad other similar items that has grown over the past 2 decades.

My thought is that one day when I am 80, I will sit and read these cards and be reminded of a time that I was loved and surrounded by those that I loved. That memories will flood in and drown out the sadness I see so often in the nursing homes I visit. That the effort to read someone’s poor handwriting inside a Snoopy-themed missive will pay off in smiles and remembered inside jokes.

Hold that thought. This will be the bow we put on the boxes that are sometimes painful to open.

 

 

But first, let’s talk about what happened in 2018 in Medicaid

 

Its been a wild, wild Medicaid ride hasn’t it dear reader? I looked back at the topics in our Monthly Medicaid News Roundtables, and made a short list of major happenings in our world this year:

 

Work requirements; Good vs Evil; Darth Vader; Orange Man Bad

It’s all a bit overblown, don’t you think? Reasonable people can disagree without casting each other as Nazi’s. At least they used to be able to. I yearn for a return of reasonable people discussing Medicaid. Hint – it does need fixing. Start there.

Another hint- a rebalancing of the state/federal “partnership” is long overdue.

 

Expansion on the ballot

This one took me by surprise. I wasn’t surprised that in state after state people voted for it (put any entitlement on the ballot and of course people will vote for it). I was surprised that it can even work this way. And I’m still not sure it can because it all has to go through the budget process. Stay tuned…

 

Social determinants

All 3 of these things are true:

  1. I believe food, clothing and shelter do impact healthcare outcomes
  2. I can’t sit through another academic presentation on this
  3. Its time to share info on specific, practical, starting point strategies. Go!

 

Managed care in the Tarheel State

North Carolina was added to the “managed care” column this year. Seems like 85% of the 2018 Medicaid conversations I had were around this. Now if we can get through the protests (I know we don’t have them yet, but I will bet you anything we will).

 

 

 

And now back to the things you think about sitting next to a fireplace (a wood fireplace, the only real kind)

 

Yes, it gets cold even in Birmingham, Alabama. Not as cold as some of the places you lunatic Yankees live (I’m looking at you my good friends in Michigan, Ohio, Maine- I mean, why not just live at the North Pole? That’s the one with penguins, right? Or is it the south pole? Or both?).

And I love fire.

I was the kid who other kids could not play with because I taught them how to play with fire. My first “date” was when I was seven and I went to see E.T. in theatres with a little girl my age. When her parents dropped her off, the first thing I did (to try and impress her?) was walk over to the nearest tree and show her how to strike a match and throw it at the tree.

I like fire. And fireplaces.

Many of you who have spoken to me the past few years know I have been slowly remodeling a 1974 elevated ranch. Well, I finally got around to fixing the fireplace. Which really was a chimney repair/ash dump investigation/damper replacement/flue cleaning/new cap install project. Just a small project. Only took me 2 months.

But now its done. And we sit by the fire whenever we can (I have come to think that first-thing-in-the-morning fires are the best. How nice it is to start your day with a fire and its heat and its light and the smoke wisping up into the flue as you drink a cup of coffee. Or see you children stumble out into the living room in their pajamas).

And these are the things I think about when I sit next to my newly working fireplace and stare into the flames.

I do not think about Medicaid.

I think about people.

 

My mom brought me a stack of old cards and I finally cried about Daddy dying for the first time almost a year after he died

 

As many of you know, Daddy died a year ago today (12/28/2018). My grieving has been different than most of my family members. For whatever reason, I did not really cry a lot when it happened. Or at the funeral. Or pretty much the entire year of 2018. I did cry here and there, but only a little.

I wasn’t holding it back (at least I don’t think I was). But it was noticeable to others, including my daughter who asked me – “Are you not sad? Now that Papa is gone?” I didn’t have a good answer. And I still don’t.

I am sad. But also not. Daddy left me with a clear view of death.

And its not that I don’t think about. I think about him most days. But in a good way. Memories of his little strange habits, or of conversations we had. Or ones I wish we would have had.

I try to spend my rememberings on things from when he was most alive. I do try to block out the gruesome final months of his life as he succumbed to brain cancer.

That was hard.

So hard that all I could do was work. Sitting in the room next to his, working away. Furiously trying to deny that he was 10 feet from me, his body and mind mangled more each day by this evil opponent.

I have many, many, many regrets in my life. But the one that has stuck with me most this past year is that instead of spending most of my time next to his bedside holding his hand in those last few weeks, I instead spent most of my time typing and analyzing and staring at a computer just a room away.

I’m sorry about that, Daddy.

 

 

I have learned in recent years, sometimes all our urges to find a silver lining, to make a happy ending, to put a bow on it (just look at all the idioms we have for this)- sometimes we can’t overcome the brutality of certain events. Sure, we can say “they’ll always live in our hearts” (never has made sense to me), or “make the most of life since its so short, and it will be ok as long as you live a full life” (always seemed like it missed the main point).

Sometimes we have to face the reality of loss. We have to accept for what it is. We can’t deny it. We can’t escape forever into our hobbies or pursuits or careers. Loss (primarily death) refuses to actually be transformed into something less than an awful, horrible, total thing.

We can’t put a bow on it.

 

 

I can still remember calling a friend and colleague who shares this Medicaid world of ours last February. I was at the Medicaid Innovations conference in Florida, and had stepped out to make a call to Dr. G.

The purpose of my call was to ask his opinion on a partner I was considering bringing on. Dr. G is someone whose opinion I trust (and his judgment even more). He started out as a client years and years ago.

And he is the reason I have a beard.

Dr. G was a key client stakeholder for a giant technology implementation contract my company at the time had (if I remember correctly, about $80M over a few years). In my first meeting with Dr. G, at the end of the meeting he had a new agenda item. It went something like this:

“You seem like a very impressive young man. And it seems like you have everything in order for the preparation for this project.”

He paused.

“But you look so young. I for one would appreciate a little more gray hair on a project of this size and complexity.”

I have always had a baby face.

I thought for a moment.

“Give me a month, Dr. G.”

 

I spent the next month growing a beard to try and look older (it used to work for my friends in high school when they tried to buy cigarettes, so why not for this?)

At our next meeting, I pointed to the beard.

“Do you feel better now, Dr. G?” I asked.

“Yes.”

It was the start of a wonderful working relationship, and I have gotten to know one of the most committed, honorable men in this space. All because I threw away my razor.

 

 

Back to the call from sunny Florida this past February.

After giving me his insights into the question that occasioned the call, he also asked how I was doing.

And I told him it was hard to have not cried about Daddy yet now (at that time) that it had been more than a month.

And he told me of the story about how it took him a long time to cry about the loss of his parents. He shared a sacred part of his life with me that day.

And he let me know it was ok to not cry yet. But that it would come.

And to hope that God would bless me for it to come in a private moment. For when it comes, there will be no holding back the tears. It will overwhelm you and consume you and take control of not just tear ducts, but also breathing and your muscles and all your emotions and your mind. It will be an experience of recognizing the totality of the loss.

And then it will somehow be better.

 

 

My mom has been cleaning out things since Daddy died. I think people do this for various reasons. Some people do it to get rid of clutter. Some people do it to busy themselves and avoid thinking about the one who has died.

Some people do it as a way to remember the people who have died.

I think that’s what Momma has been doing with all her cleaning.

And in cleaning out things, she found a stack of letters and cards of mine. She brought them over one day in early November and left them on my kitchen counter.

At first all I noticed was the letter from my elementary school congratulating me on coming in 2nd place in the city-wide spelling bee. And I remembered how much I did not like the experience of 2nd place. And I remember vividly the face of the little girl who beat me (I do not remember the word I lost on).

And I told my children the story of this. And they laughed. And that was that.[5]

The next day, I saw the stack of cards on the counter again. If your house is like mine, there is a constant battle between you and one spot on your counter to keep it free from mail or books or keys or change or Home Depot receipts. The stack of cards was in that spot, staring back at me.

That’s when I noticed the other things under the spelling bee letter.

I opened the first one and began to sob. It was a highschool graduation card to me from Daddy’s very best friend. Emmet Ladner. Emmet and Daddy became fast friends on the Mississippi Gulf Coast due to their shared love of fishing. Emmet had died 10 years or more ago and I watched Daddy miss him.

And then I opened more cards. Many of them from Daddy. Or from aunts long dead. Or friends forgotten.

And I simply could not stop crying. But it was of joy. I was remembering the good things, all the many people God had placed in our lives and the times they thought enough of me to spend a few bucks and write down a few thoughts about me that they felt in their hearts.

It was not – as Dr. G had wished for me – a private moment.

My wife was there to hug me. My kids were there to see my cry. And I’m glad they did.

 

 

 

3 Kinds of People

I think this year I realized recently that there are mostly 3 kinds of people:

  1. Those you don’t want to be around. You choose to avoid these.
  2. Those you do want to be around, but can’t. They may be far away, they may dead, they may have an illness that prevents contact. They may be missionaries in a country where they have to be almost like secret spies for Jesus or else get killed, and that’s the reason you probably won’t ever get to see them again. There may be an un-crossable emotional rift between the two of you, spreading across and between your hearts like a chasm. With only darkness and echoes where what once was joy and laughter. And a bond you never doubted until one day it simply wasn’t there.

There are many reasons that created situation #2- the people you want to be around but cannot.

And that leaves us with the 3rd kind:

  1. People you do want to be around and still can.

 

I now think about the people in #2 a lot. And you should, too. You shouldn’t avoid it (if you do).

Its good to think about the people in #2. It is important to miss them. Important to grieve. To mourn. To ache. To cry.

 

But I need to start paying more attention to the people in group #3. (And so do you).

 

And this is where we put the bow on all this.

 

 

 

Card by card

I’m still saving this big ole’ box for when I am old and gray. I’m working on the old part. And the gray pokes through. But hopefully I still have decades longer to fill this box up and look at it when I am old.

But – I did sneak a peak at a few of them when Momma brought them over. A little stack. A small bundle of memories that jarred in me tears of joy.

And I would like to share just a few of those cards – or rather share a bit about who sent them- with you before we land this plane.

  • Emmet and Nell-  They are both dead and gone, but some of my earliest memories are of them.
  • Jo Elaine –Jo is my aunt and she’s a peach. On my Nanny’s side (who has been gone a long time). Jo is one of many aunts who always thinks of me on birthdays even though I rarely see her.
  • Bobby and Betty –Mr. B was also one of Daddy’s very best friends. I remember riding my bike next to he and Daddy as they ran at 4am each morning in Gulfport, MS. Mr. B was a Marine, rough around the edges but with a gooey center that loved people. He was a good man. He is also now gone.
  • Carrol and Nancy –Carrol was a true friend to Daddy in his toughest times, hiring him to work in his hardware store during one of Daddy’s hardest bouts of depression (it lasted 3 years that time). Nancy died in a car crash in the rain on an interstate exit ramp. But she was a dear friend to my mom before she left. Momma still misses her and I think of her every time I pass that exit ramp.
  • John and Louise – a sweet, sweet couple who managed a large farm operation in Kiln, MS (where I watched Brett Favre play highschool ball). They stopped smoking when 7 year old me told them I couldn’t be around it. They are both gone now but in no way forgotten.
  • Ganky and Pappy- Pappy was a retired railroad man and he sure did love Ganky. She was the first person I ever heard of with Lou Gehrig’s disease. Pappy once snuck into Daddy’s garden in the middle of the night to dig up and replace small tomato plants with very large ones to convince Daddy of the astounding overnight effectiveness of Miracle Grow. They have both been gone a long time.
  • Aunt Annette – one of my mom’s aunts who still sent me cards even though she had been estranged for decades. My mom misses her a lot.

And so many more even just in this little stack. From my siblings, from Momma and Daddy. Somewhere in the big box is a letter from my friend Cecille who died (along with her little brother) when she was hit by a train in her late teens. Way too many to write about.

What do I take away from all these cards? People come and go and everyone dies. But in the in-between parts, the times you spend with them, the times they still send you cards (and even after that when you read the cards years later)- something amazing happens. Somehow, despite all the insurmountable despair of loss we all must face, somehow we have the capacity to love one another.

Let’s do more of that in 2019.

 

One last detour

I almost didn’t write this part up. This thing has gotten way, way longer than I intended. And I hope for the 2019 Year in Review I can find a topic besides death and loss. 3 years in a row is surely enough.

But this part is fun.

When I was kid, we went to every Auburn game. Home and away.

This was before that jackass Alabama fan poisoned the big oaks on Toomer’s corner.

Back when you could still park all over campus on gameday, in crazy places. And camp out for 3 days before the game with 100,000 of your closest friends.

Like an idiot, I hated much of those times as a kid. Or at least I thought I did.

Now, I do things like return to Auburn and walk around with my kids. Just like Daddy did with me.

Not knowing why, we often return to the places our fathers took us.

What was really crazy, was that Daddy would just walk on the field after a game and walk into the locker rooms just to talk with players. And after that we would walk over to the players dorms and hang out with them. So as a 12 year old I’m chilling with the dude that just kicked the winning goal against LSU. Or the guy that missed the pass that could have beat Arkansas in the last 3 seconds. Those 2 guys have very different moods, by the way.

But the point is that Daddy had a way of getting into places (and people’s hearts) simply by acting like he was supposed to be there. Let them tell you no if they feel they must. But until then, sneak into the stadium.

And that’s what we did a few weeks ago. Passing through Auburn on our way back home from a trip with the kiddos.

There was one gate open at Jordan-Hare stadium that day (pronounced Jur-dan for those of you who don’t know). I snuck in first and waved to the kids to follow.

There was a worker there. He looked at me.

I froze.

“I gotta lock the gate, so please make it quick.”

I had the feeling he sees this a lot. And he was so kind and probably is to every Auburn fool wandering back in. Whoever he is, he was my hero that day. And I hope I get chances to be so kind to others in need of sneaking into stadiums, too.

We go back to the places our fathers took us.

 

Wrapping Up (Finally!)

So I know what I need to do now. How 2019 needs to go.

My box is overflowing.

I need to send more birthday cards so others can put them in a big box and pull them out one day and go through each one and defiantly shake their fist in the face of death and loss and separation and tell the Evil One he has not won because there was joy. There was love. There still is. But – most importantly- there still will be.

And it can be forever for those of us who choose it. Beyond time, forever joy. With our loved ones and with Christ. For all of you readers who are non-believers (so many of you are, and I hope you know by now I love you regardless of any differences of opinions or beliefs), suffer me one more time in 2018 to share the simple gospel:

You (and me and everyone ever born) are a sinner. You need a savior. His name is Jesus.

 

Merry Christmas and Happy New Year my dear readers! You are loved by me, each and every one of you. If you like you can print this out and put it in your box and count it as a card from me to you. Me thinking about you and writing it down.

Please don’t stop writing in (clay@mostlymedicaid.com) and calling (919-727-9231). You have no idea how much it means to me when you write in and tell me your thoughts about what I write.

War Eagle!

Onward and Upward!

Trystero: The Father Sent the Son to Save the World (English)

 

 

 


[1] I have found my old love of footnotes again. It’s like a little side conversation beyond me and you. Titles that were also considered:

A Box of Letters

Looking At Life With Clear Eyes and A Full Heart

Memories as a Gift to Get Us Through Our Journey

Returning to the Places Our Fathers Took Us

 

[2] For those of you who have enjoyed my musical recommendations in the Roundup over the years, this song, album and band are in my opinion one of the most important things to happen to music in my lifetime. For people who have never heard The Weakerthans, I tell them their art is the closest thing to perfection in the combined genres of music and poetry that I have ever encountered. It may not be your style – but I drove from Baltimore to Toronto once just to see them play and its still one of the best life decisions I have made.

[3] For a fun look at the greeting card industry (including average prices, which have gone way up since the mid-1990s), see https://www.thesprucecrafts.com/greeting-card-industry-facts-and-figures-2905385

 

[4] Oxford forever! Grammarians, unite and #Resist! https://en.oxforddictionaries.com/explore/what-is-the-oxford-comma/

[5] 6 sentences in that segment started with “and.”

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Clay’s Weekly Medicaid RoundUp: Week of December 24th, 2018

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2Ve9DwR

 

For optimist readers- http://bit.ly/2V9u2Dn

READY FOR MEDICAID INNOVATIONS 2019- I will be there again this year (my 9th time), chairing one of the very best Medicaid events you can go to. Also, its sunny Florida in February (I’m looking at you, Michigan). If you decide to go, let me know and we can meet up. Check it out here – https://www.medicaidinnovations.com/

PELICAN STATE TO START USING IRS DATABASE TO CONFIRM MEDICAID ELIGIBILITY- After a few weeks of taking a beating in the news over blowing $80M on non-eligibles, Louisiana is rolling out several news stories about an enhanced system. To be fair, it looks like the enhancements were planned for some time (so I guess they have known their system is crappy for a while but still kept overpaying millions?). The new system will start using tax data for bennies in May of 2019 (one month after we all file our taxes).

AND ON THAT NOTE, A BRIEF MATH DETOUR- I’ve been working on a little math exercise where I try to figure out how much of my own personal taxes help pay for Medicaid. Its not easy (mostly because of the imaginary way we handle group expenses in our country under “budgets” and “debt”). But I am getting closer to a workable framework. Here’s my current, early, certainly wrong (but I invite you to provide alternative estimates) evaluation based on income groups. If you make $65k/year, then about $1,800 of what you pay in taxes goes to Medicaid spending (about 1/3rd the cost for one average bennie; about $185 from your taxes is lost to Medicaid fraud). If you make $120k/year, then about $3,400 of what you pay in taxes goes to Medicaid spending (about 2/3rds the cost for one average bennie; about $350 from your taxes is lost to Medicaid fraud). And so on… Once I am done, I will publish the broader analysis and will invite comments, corrections, etc…

BUCKEYE STATE JUST CAN’T GET RX RIGHT- The report of CVS spread-pricing shenanigans in Ohio will be conveniently delayed until after legislators consider a budget in 2 months. Note to CVS Grand Pooh-Bah: whatever you are paying your lobbyists in Ohio, they deserve a raise. In a related (?) note, reporters in the state are trying to get answers about why the state still has not implemented a unified drug list that was rolled out by Kasich as a key initiative 2 years ago (and in October of this year was still projected to go-live Jan 1, 2019). Medicaid officials announced this week that the effort would be “delayed indefinitely.” You know who opposed that initiative? PBMs. Why, you ask? Because they could no longer keep their rebate deals secret and states would know how much rebates they would have gotten vs what was passed on to them. Am I being too hard on you this week, PBMs? Open invite to come on the show and explain yourself anytime you like.

ALOHA STATE INCHES FORWARD MEDICAID PAYMENTS FOR HOUSING- Hawaii is leading the way towards getting Medicaid dollars approved for housing. An existing waiver that pays for house (or apartment) hunting help is being expanded. While the dollars can’t pay for rent, they can be used to help with all the effort to find a place. There are 8 other states with a request for similar funding for supportive housing from CMS.

 

SHOW ME STATE CONSIDERS THOSE EVIL WORK REQUIREMENTS- By now you can fill in the rest from here, right? Won’t be effective, just an evil ploy to kick people off rolls, Orange Man Bad.

 

SNEAKY STATE REPS IN THE GRANITE STATE TRYING TO UNDO CMS DEAL- This is pretty interesting. A week or so ago, CMS approved a New Hampshire request for work requirements (aka, “how the process works”). Without getting into the weeds (are there weeds in NH? In my mind its this idyllic place, with nothing out of place), duly elected reps in NH negotiated a deal in which the state’s expansion program can continue IF there are work requirements in place. So that got passed, then CMS approved what was agreed to by both parties. Now, Dems (Rosenwald and McWilliams) are introducing bills to make work requirements illegal in NH. When you’re opponents keep changing the rules, its hard to keep up. Will be fascinating to see how this one plays out. Some of the CMS comments were fairly clear on the tradeoff between expansion and work requirements as the heart of the bargain.

 

WAIT- YOU MEAN WE HAVE TO PAY FOR THIS EXPANSION THING BY PASSING A STATE BUDGET? Idaho activists were able to get expansion voted in back in November (seems ages ago, doesn’t it?). But now it seems the next steps are out of their hands. From what I understand in Idaho, each year this group of people called “legislators” get together in this place called the “Capital” and they manage something called an “appropriations process.” They have to make these things called “decisions.” And sometimes they have to choose between different priorities. And – here is the shocking part- some Idahoan reps think the function of Idaho state government is broader than Medicaid. Something about education, roads, state pensions – I mean does it matter?. Somebody connect these doofuses to Alexandria – she clearly has it all figured out.

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… Actually, in the spirit of Christmas, let’s just pretend there’s not bad guys stealing 10-20% of all the funds meant for the most vulnerable this week. We’ll pull our heads out of the sand again next week/year.

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (burn all those amazon boxes) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Want the Curator News Pack for this week’s Roundup? Medicaid News Curator Volume 4

 

Trystero: Fadern skickade Sonen för att rädda världen.

 

 

Posted on

Clay’s Weekly Medicaid RoundUp: Week of December 3rd, 2018

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2B0dxAj

 

For optimist readers- http://bit.ly/2B596nU

 

MAINERS GETTING MORE MEDICAID FEB 1- After a long battle against Medicaid expansion (which gave us a lot to cover for years), LePage may have finally lost. A judge ruled the voter-approved expansion must go forward. LePage will be gone (doing whatever Mainers do when they retire and its winter, I guess. Something in a cabin?), and the new Good Guvn’r Janet Mills will come in Jan. 2, with magic wands, puppy dogs, unicorns and Medicaid expansion promises.

 

NEW HAMPSHIRE WORK REQUIREMENTS STILL ON- Seems CMS still gets to decide which parts of requests it does / doesn’t approve. CMS approved NH’s work requirements waiver (basically as a trade-off to let them keep expansion). CMS did not approve a provision that would allow seasonal workers a different way to add up their hours to reflect the surges in employment they have during certain times of the year.

 

FLORIDIAN BENNIES NOW HAVE ONLY 30 DAYS TO FILE PAPERWORK- Several states have requested the option to reduce retro-active eligibility from 3 months down to 1. Florida got approval for this and the change will go into effect Feb 1. Officials estimate it will save the state $98M (women and children are exempt and still have 90 days). Other states with recent approvals for the same request include IA and KY.

 

PELICAN STATE PAYING MILLIONS FOR INELIGIBLES – Louisiana spent at least $60M and as much as $85M on bennies who were not eligible, according to an auditor’s new report. The system to confirm self-reported income was not effective at getting info about changes in income.

 

FORTUNE SEEKERS GO TO COURT- Did you know that’s one of the demonyms of Idahoans? A taxpayer-rights advocacy group is suing to stop the Medicaid expansion voted in by 60% of voters in November. According to the lawsuit, letting voters decide these types of things is “A sweeping and general delegation of legislative power with uncontrolled, unrestricted or unguided discretionary power [that] exceeds constitutional limits…”

 

MINIMUM WAGE HIKE IN JERSEY TRIGGERS $200M MORE IN MEDICAID SPEND- When you raise the wage for everyone, that includes Medicaid home health workers.

 

CALIFORNIA TO SPEND $3B ANNUALLY TO GIVE ILLEGAL IMMIGRANTS MEDICAID COVERAGE- A bill from last year is expected to get re-introduced in the next session. Would add about 1.2M people to the rolls.

 

 

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. Erik Dewayne Lean of Greensboro, NC was sentenced to 18 months for stealing $420k in a kickback scheme for his counseling business. Rajendra Bothra (of Detroit) and 4 of his buds were charged this week for stealing $500M from Medicare and Medicaid (so ineligible for this week’s award, but notable). How, you ask? By prescribing more than 13M doses of opioids. Based on initial reports, this could come close to some of the FL pill mill scandals from 10 years ago. Samuel Okere of Oklahoma City was sentenced to 1 year in federali lockup for stealing $141k in Medicaid counseling bucks (services not provided). John Ndunguru of Fairfax, VA has been charged with using his home health company to steal $4.5M from Medicaid. Mr. Ndunguru made submitted false Medicaid claims for patients not approved for long term care services. Still in VA (but now in Charlottesvile- about a 1hr 51 min drive south west from our last story), husband and wife team Dennis and Cheryl Gowin stole $210k from Medicaid by not disclosing that Dennis had a felony conviction (which would have made him not eligible as a Medicaid provider, or even become a licensed counselor in VA). Anil Desai of Hotlanta has agreed to pay back the $213k he stole from Care and Caid by getting paid for drugs they never provided to patients. Tara Rose of El Paso, TX plead guilty to stealing $1M from Medicaid using her speech therapy business (“Beyond Words”) to bill for imaginary patients and services that never happened. Faiz Ahmed of Houston, TX was sentenced to 5 years in prison for stealing $4.1M by ordering unnecessary tests. There’s actually more this week, dear readers. I am just tired of typing.. This week’s winner- Mr. Ndungura of Fairfax, VA! Taxpayers, you lost at least $510M in the last paragraph.

 

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (finish up your Christmas shopping? We do all ours online) and keep running the race (you know who you are).

 

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Want the Curator News Pack for this week’s Roundup? Medicaid News Curator Volume 3

Here’s the one for the Fraud stff- Medicaid FWA Curator- Vol 4

Trystero: el Padre envió al Hijo para salvar el mundo.

Posted on

Clay’s Weekly Medicaid RoundUp: Week of November 12th, 2018

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2zWAhka

 

For optimist readers- http://bit.ly/2zVLbqh

 

MEGA RULE MUTATES- After a loooooong windup and much speculation, CMS finally showed its cards on possible changes to the Mega Rule. (Do you get the feeling they wait until early November for big stories just to make sure there are interesting convos in the NAMD hotel happy hours?) Highlights: Possible relief on cert for all those rate cells (may go back to ranges), 3 years to put on your big-boy pants related to pass-through payments, and more grace on using telehealth to meet network standards. And oh yeah – some stuff about making sure all you turkeys stop using different rate cells to game the federal match.

 

IL CRIES UNCLE- Following many other states (who are following judge’s orders in their own states), the Land of Lincoln (R-IL) has decided to open the floodgates on Hep-C coverage. Now no signs of disease or proof of sobriety are required to get the pills that cost about the same as a souped-up Civic. But hey- it used to be a new Vette.

 

MICHIGAN GETS TREATED LIKE AN ADULT- Add a W to the win column in the “restore a modicum of power back to the states game.” CMS approved Michigan’s request to negotiate their own deals for pricy drugs based on whether they actually work for the patient. This CMS approval comes 4 months after a similar gig for OK and a denial for MA. Right now the MI deal is focused on 4 drugs. I’m sure the list will expand, and if you say the magic words – “value-based-care,” “population health,” and“big data,” – four times fast, under a fool moon, wearing green slippers, the list of the next 4 drugs will magically appear in your left hand (if you’re left handed; else, your right hand).

 

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. Idris Talib of Columbia, SC got five years in the slammer for stealing $400k using false claims for counseling. Head on up 1 state to NC, where we meet Renee Borunda, who managed to steal $225K using another therapist’s billing ID for Medicaid claims that didn’t happen. Keep heading north until we get to Niagara Falls, NY (cool place if you haven’t ever visited), and we learn about Sadat Khan who used Wego Taxi Tours to steal $50k from Medicaid. How did he do it you ask? By falsifying pickup location addresses so the trips would appear longer and get more mileage reimbursement. Lets drop down to the paradise known as Detroit for our next shining light of Medicaid fraud- Jacklyn Price. Ms. Price and buddies stole $8.9M from Medicare (so can’t win today, sorry!) using a home health scheme. Over in Brooklyn, Yvette Juarez was picked up on a pretty decent-sized member fraud. She made too much money from her daycare business to be eligible for Medicaid, but falsified income statements in order to get about $72k in benefits. Now on to PA- 4 people operating “Moriarty Consultants” stole as much as $87M from Medicaid by fabricating personal care services claims. It gets good, in addition to boring stuff like faking timesheets, they made up employees and paid kickbacks to bennies to help pull it off (remember, fraud is most effective when you work as a team). Team Moriarty – you win! Your creativity and volume put you over the top; you do not live up to your namesake, however.

Taxpayer tab for this paragraph – about $96M. Work harder- and don’t complain or have bad thoughts about it, or else you’re a meanie!

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (enjoy the early winter: apparently there are less sun spots right now?) and keep running the race (you know who you are).

 

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

 

Want the Curator News Pack for this week’s Roundup? Medicaid News Curator Volume 2

Here’s the one for the fraud stuff

 

Trystero: Oče je poslal Sina, da reši svet.

Posted on

Clay’s Weekly Medicaid RoundUp: Week of November 5th, 2018

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2SVN6DU

 

For optimist readers- http://bit.ly/2SSPPhv

 

VOTERS DECIDED TO GROW MEDICAID IN 3 STATES; SHOT IT DOWN IN 1- Idaho, Nebraska, and Utah all decided to “cover” more people with Medicaid (and to spend more money from the pockets of the people who voted against it (40% against in Idaho, 47% against in Nebraska, and 46% against in Utah). But hey – screw those guys! We voted yes, and now they have to pay for it. Losers buy!. 

IN RELATED NEWS, VA IS SHORT $460M IN ITS MEDICAID BUDGET- Sort of related, anyway. These are “unforeseen” costs that occurred before the expansion decision. I wonder if they would have disclosed these costs before the expansion decision, would that have impacted the expansion decision? Current theories as to the overage are higher costs under managed care than expected, and higher than expected CHIP enrollment. Most legislators in the state are already messaging that school spending in next year’s budget will have to go down to pay for this whoopsie.

 

MORE CONSOLIDATION IN THE IL MCO MARKET- Harmony and Meridian health plans are merging after the recent WellCare acquisition of Meridian for $2.5B. Harmony was struggling and was dinged back in May for having insufficient network.

 

CMS WORKING ON NEW RULE FOR STATE FLEXIBILITY ON NEMT- According to a notice of proposed rulemaking last week, CMS is cooking up a new reg that will give states some relief on how much they have to spend on non-medical transportation for Medicaid bennies (states have been asking for this for years, with AZ being the most current example I am aware of).

 

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. Get out your wallets taxpayers – we have some Medicaid fraud to pay for! ImmediaDent (a dental provider with a weird name) and Samson Dental Partners of KS have settled false claims allegations with three states (KY, IN and OH- I guess they didn’t want to fraudulate in their own state?) for $5M. What did they do? Billed simple extractions as surgical procedures, billed scale and root planings that never happened and put dental employees on volume-based commission plans. Sophia Eggleston of Detroit was convicted this week for her role in an $1M home health fraud scheme hitting the Medicare coffers. Travis Moriarity of Pittsurgh (and 3 of his buddies) were charged with defrauding PA Medicaid out of $87M this week. How did they rack up such a bigly fraud, you ask? With bogus claims for personal care services, care coordination and NEMT. If you want to hit the Medicaid fraud big leagues, you’ve got to diversify, people! Bernard Oppong of Blacklick, OH was charged with a pharmacy scheme. Oppong would partner with a pharmacy to send special medical crème to Medicaid members without ever examining them. So far all I have is that this is a “multi-million dollar” fraud… Pretty big whopper of a hospice fraud concluded this week when Patricia Armstrong of Coppell, TX plead guilty to her role in the $60M scam. Armstrong and others stole from Medicare and Medicaid by signing up bennies who didn’t need hospice and then billing for it. They forged terminal-illness certifications. Celestine “Tony” Okwilagwe, et al of Garland, TX were convicted for stealing $3.7M from Medicare and Medicaid using a home health scam. Bonus points- they were already barred from participating in any federal healthcare program. Jennifer Gardner of Summit Township, PA got $104k in member/provider fraud bucks illegally. Let me unpack this one: Ms. Gardner had one of these deals where Medicaid gives you cash to pay your own personal caretaker in your home. But her attendant moved away, she didn’t replace him and kept cashing the checks. Ms. Gardner, you win! You gave us a great illustration of the clear risks of this model! Thank you. Taxpayers, you lost about $159M in this last paragraph.

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (do the first round of leaf-raking) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Want the Curator News Pack for this week’s Roundup? Here you go- Medicaid News Curator Volume 1

Here’s the one for the fraud stuff

Trystero: Otec poslal Syna, aby zachránil svet.

Posted on

Clay’s Weekly Medicaid RoundUp: Week of October 29th 2018

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2zqq6nM

For optimist readers- http://bit.ly/2zmJimb

 WELCOME, MRS. MAYHEW- After bringing some predictability to the Maine Medicaid budget, Mary Mayhew was tapped to head Medicaid efforts at the federal level earlier this month. Her official title will be CMS Deputy Administrator. Congratulations, Mary!

BADGES? WE DON’T NEED NO STINKIN’ BADGES- If you thought CMS was holding the phone on work requirements while the KY lawsuit sorts out, you were wrong. CMS approved Wisconsin’s request to add a work requirement feature to its Medicaid benefits package. Also important- Wisconsin is a non-expansion state (many work requirements resisters have been holding out hope that CMS won’t approve work requirements in non-expansion states). CMS did not approve the state’s request to add drug testing requirements for members, but they did allow them to ask bennies about risky health behaviors as part of coverage determinations.

  

NEITHER DOES VIRGINIA- Sources say VA officials plan to submit a work requirements request to CMS by this Friday. Current proposal includes work/volunteer requirements (or job classes) and premiums up to $10/month. Many conservative lawmakers feel the new proposal is too watered down to matter, though.

 

 POSSIBLY ALSO NEITHER DOES MISSISSIPPI- MS Medicaid officials are chatting it up with CMS now that the public comment period on their work requirements request has ended.

  

NEBRASKA VOTERS TO DECIDE EXPANSION AS WELL AS WHICH MODIFIERS SHOULD PAY ON 99213 CODES IN THE NEXT VERSION OF THE POLICY MANUAL- Initiative 427 puts Medicaid expansion in the hands of Nebraskans next Tuesday. I’m not concerned they are low-informed voters on the details of Medicaid. Not at all. Nothing to see here. Move along.

 

 VERMA TROLLS MEDICARE-FOR-ALL MOB; THEY TAKE THE BAIT- Hey if Nebraskans who mostly probably don’t know the difference between Medicare and Medicaid can decide whether to double spending on it, why can’t the twitterverse tell CMS Administrator Verma (in the very polite ways we have come to expect from our leftist friends, of course) she was a terrible, doubleplus ungood person to tweet this in the spirit of Halloween. Remember, questions like “how would we pay for it?” and “does this even make basic logical sense?” don’t matter. All that matters is feelings and a deeply held conviction of a virtuous “resistance.”

 

OHIO MOVING UP HEP-C TREATMENT- Medicaid bennies in OH no longer have to wait until their Hep-C progresses to get specialty drugs. Starting Jan 1, OH will pay for treatment for any one diagnosed with Hep C. In tech speak, OH used to pay for patients with a Fibrosis Score (F score) of F2. Now the state will pay for all Fscores (starting at F0). Last year the state went from only paying for F4s to F2s.

  

CA PAID $4B OUT IN “QUESTIONABLE” PAYMENTS- Some pretty egregious examples in a recent state auditor’s report. Biggest findings – state kept paying MCOs and docs for services for 453,000 members who were ineligible for benefits. Worst example- an MCO got paid $383k for care for a member in LA County who had been dead for 4 years.

  

FINALLY, AFTER 300 YEARS, CMS APPROVES NC WAIVER- Congrats to the team that’s been working on bringing managed care to the state for the past few years!

 

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. Edwardo Yambo of Lake Grove, NY stole $939k for false lab claims. In addition to billing for claims his lab wasn’t even equipped to run, Mr. Yambo operated the lab without a director (a big no-no). Lanice Stamps and Tia Smiley of New Orleans were convicted this week for their $1.1M fraud in Louisiana using a bogus behavioral health company to steal from Medicaid. Bonus – both fraudsters were also Medicaid bennies. Not sure I have seen double-dipping on the provider and benny fraud side before. Nikkita Chesney of Bridgeport, CT plead guilty this week to using 150 stolen member IDs to file more than $1M in false claims. Celestine “Tony” Okwilagwe lead the way in convictions for a pretty large home health fraud in Dallas this week. Along with 3 of his buddies, Tony got popped for stealing $3.7M from Medicare and Medicaid. Special points on this one since 2 of these dudes had already been excluded from any federal health-care program for prior convictions. Matthew Neiswanger of Baltimore was in court last week and agreed to pay back $2.2M his nursing home stole from Medicaid. How did he do it? Evicting higher cost patients (sicker) and false claims. Joseph Dubin and David Dubin (father and son, a first for the follies) of Austin, TX were convicted of stealing $300k in a kickback scheme involving Medicaid psychology services. Fraudster and Sons paid another fraudster to refer Medicaid kids to their mental health services company. Lanice and Tia you win – I am just entranced by the double provider/member fraud angle! Plus, $1.1M is a pretty good take home. Taxpayers, you lose – about $8.2M in the stories covered in this paragraph. Work harder! Gotta pay for all that fraud somehow…

New content alert- The Medicaid Fraud, Waste and Abuse Curator Volume 1 is out. Includes links to the stories above and a lot more. Check it out here.

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (clean your chimney, its that time already) and keep running the race (you know who you are).

 

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: piyāṇan vahansē lōkayaṭa gaḷavannaṭa putrayā evū sēka.

Posted on

Clay’s Weekly Medicaid RoundUp: Week of October 8th 2018

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2RI7RCi

For optimist readers- http://bit.ly/2RKh1hW

 

BUCKEYES TO GET MORE OPTIONS ON OPIOID RECOVERY MEDS- Based on what I am hearing, looks like Ohio may be removing prior auth for more drugs besides just suboxone and generics for buprenorphine and naloxone. If you know more, please dial into the show on Monday and weigh in.

 

NEW PROJECT TO UP CAID IMMUN RATES- If you’ve been around this Medicaid world a while, chances are you have bumped into the immunization “registries” (glorified excel files in a Medicaid official’s computer, usually). The CDC is funding a new consulting project (Nat’l Academy for State Health Policy got $800k) to figure out how to better integrate this data, encourage providers to submit more of it and close gaps for certain vaccines (i.e. Medicaid rotavirus rates for kids are 12 points lower than commercial).

  

MORE RUH-ROHS IN THE OH PBM SCANDAL- We will cover this in Monday’s show, so tune in. The gist: turns out one of the reasons Centene’s rx costs were more than other MCOs (all of them got caught up in the spread pricing scandal), is because they used their subsidiary (Envolve) as a sort of middle-middle man to the PBMs.

  

HOW MANY YEARS IS IT OK TO NOT HAVE A MEDICAID INSPECTOR GENERAL IN A STATE? 4 years is the answer if you’re Kansas. After the top Medicaid oversight spot (over the $3B program- but hey that’s chump change when its those taxpayer chumps funding it, right?) sat empty since 2014, the seat is now being manned (wo-manned, actually) by Sarah Fertig. Congratulations, Sarah!

 

CONGRATS TO OUR FRIENDS AT WELLCARE- It’s the time of year where we see which MCOs are doing better per NCQA quality ratings, and Wellcare just got high marks in NJ and NY. Congrats!

  

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. Vicki Chisam of Batesville, AR was charged with her role in a $2M Medicaid fraud (part of the Preferred Family Healthcare mental health scheme we have covered). Chisam was apparently the EHR data manipulation specialist in the crimes. She herself is tied to $589k in pilfery. Lyubov Beylina of Brooklyn (along with 7 other upstanding citizens) was charged with stealing $600k for billing for therapy while on vacation in the Dominican Republic. She also forged signatures of parents of children she was therapy-ing. Joanna Michelle Phillips of Cheyenne, WY was sentenced to 18 months for stealing $58k via false claims. Mercy Ainabe of Houston, TX was sentenced this week for her role in a patient recruitment Medicaid fraud scheme. She and her fellow fraudsters used a home health care front to bill for medically un-necessary services, pay bennies to sign-up and send kickbacks to docs. Total tab – $3.6M (but to Medicare, so she can’t win this week). Epo Onega of Staten Island was popped for using her teaching job to steal $59k with bogus speech therapy claims. Vicki- you win! Hopefully you can re-connect with some of your old workmates once you all get sentenced. Taxpayers – you lost about $7M in this paragraph! Work hard! Somebodies gotta pay for all this fraud (hint- you do, chumps). Are you a Medicaid bennie on a waiting list for a waiver program? Keep waiting! Sorry, we have to make sure we keep paying fraudsters before we open up your slot.

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (plant mums – they can actually do really well in the ground) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: Otac je poslao Sina da spasi svet. Also – chuir an t-Athair am Mac gus an saoghal a shàbhaladh.