Category: Clay’s Weekly Medicaid Roundup

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

Or you can click the one for optimist readers –  http://bit.ly/2mQQ9xn

Both are St. Patrick’s Day references. If you know why, do write in.

 

ONLY A FEW MORE WEEKS UNTIL MEDICAID STAR SEARCH– A plug for our upcoming Medicaid Star Search Webinar on April 3^rd. Sign up here- http://bit.ly/2ccl593

 

MAYO HONCHO JUST COMES OUT AND SAYS IT- Mayo Clinic’s CEO said privately insured patients will go in front of Medicaid patients, assuming comparable conditions. Both will be seen, but the one who generates more revenue will get seen first. The CEO was heard saying something about needing to keep making money to keep the lights on, and to help subsidize free care – but he was carried off by the villagers with pitchforks before reporters could understand him.

 

ANTHEM DISTINGUISHING ITSELF FROM REST OF PACK IN POLITICAL ARENA- Last week Anthem was the lone wolf supporting AHCA (AHIP and others came out against it). Now we have news of Anthem CEO Swedish meeting privately with President Trump and Price. The meeting (we expect Rachel Maddow to leak the transcripts next week) covered detailed design elements of the bill, and ideas Anthem has on how to improve it.

 

THE MEDICA STORY SEEMED TOO GOOD TO BE TRUE– Although at first it looked like an amicable exit,  it turns out the departing MN MCO ain’t going down without a fight. It gets a little convoluted, but basically Medica is arguing that the state did not have a right to transfer its membership to other MCOs without a rebid of the contracts. Seems Medica wanted to pull out saying the rates were not actuarially sound, and then perhaps trigger a rebid which would re-open rate negotiation. The state was more than happy to skip that route and just dole out the remaining membership to the remaining MCOs using rates that were established in 2015. These protests are getting harder to follow  than all the crazy drama of the English wars for the throne in the Middle Ages.

 

HHS HEAD PRICE SAYS LOSING $BILLIONS WON’T HURT MEDICAID- There’s a lot to chew on in that idea. Not the least of which is the loss to fraud each year, paying for poor quality and other obvious areas to trim. I think this quote from Price should be the starting point of this discussion: “You’re falling into the same old trap of individuals who are measuring the success of Medicaid by how much money we put into it.” Ouch. And Amen.

 

 

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.  Ethel Freeman-Nnonah and Tinisee Harris of Reynoldsburg, OH were convicted this week of stealing $101,000 by forging medical assessments and plans of care for patients treated by their business (Prudent Healthcare Services, LLC). “Dr.” Stanley Marable of Valdosta, GA will spend 2 years in prison for his role in pilfering $789k by getting paid for tooth extractions that didn’t happen. Tammie Sensenig of Lancaster, PA plead guilty this week to stealing $84k using Medicaid claims for mental health services she provided but was not qualified to render. “Dr.” Romeo Pavlic of Spokane, WA will pay $300k to settle claims he defrauded Medicare and Medicaid by billing for tests he did not perform on developmentally disabled patients. Stanley – You win!

 

 

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 (The weekend will be warmer.) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: האב שלח את בנו כדי להציל את העולם

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2nmj3V9

Or you can click the one for optimist readers –  http://bit.ly/2nmC8GK

It’s 4am. I have had 2 cups of coffee already. Let’ see what happens.

BEFORE I DO ANYTHING ELSE – A plug for our upcoming Medicaid Star Search Webinar on April 3^rd. This is your chance to hear from 3 companies trying to be innovative in the Medicaid space- without having to sit through a cheesy sales pitch (they each get 10 minutes).  Sign up here- http://bit.ly/2ccl593

 

I GUESS I’LL TALK ABOUT ALL THIS REPEAL AND REPLACE STUFF. IF YOU WANT ME TO- The best summary I can give is that the bill introduced this week has zero chance because both sides hate it. Multiple conservatives in the Senate have spoken against it, saying its ObamaCare-lite and a failure to deliver on a critical promise to the base to repeal ACA. Lefties have cranked up the fever-pitch-crazy machine, spouting non-stop EVERYONE WILL DIE headlines. The real question is will Ryan be able to throw up his arms and say “well, I tried,” or will Paul, Cruz and others hold him to the fire to put out a bill that repeals ACA even if it has to be Pelosied (ramming it through throats with just enough votes). Another interesting little twist was the CMS CMO coming out against RyanCare. Maybe he and Sally Yates can start a consulting company once he gets bagged in the next month or so? One last note – Verma made it through the Senate yesterday, one step closer to the CMS head job. Everyone I have talked to in our world says she is awesome. I will believe them over fake newsers any day. Unless of course it comes out that she is a Russian CIA spy using my toaster to read my mind (Wikileaks Vault 7 reference for those who don’t read outside of CNN).

 

AMERIHEALTH AND MERCY HOSPITAL ON THE ROCKS IN HAWKEYE STATE- So far the 2 can’t reach agreements on payment rates. This is part of how the savings happens, people. You pay MCOs to negotiate with behemoth providers for you. There is a similar story happening in MN with BCBS and Children’s hospital.

 

LAND OF LINCOLN GETS EXPANSION BILL. SURPRISE! IT’S DOUBLE WHAT WAS PROJEKTED. Sadly no one is surprised anymore. There are now 4 things certain in life (updated since I was a child): Death, taxes, MMIS projects failing and Medicaid expansion costs being double what was promised during the sales/shaming into approving phase. IL Medicaid has now spent about $9.2B on expansion, compared to the original projections of $4.6B.

 

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.  4 numbskulls in Anchorage, AK got popped this week for stealing $1M in Medicaid moo-la. Their crime? Falsifying records to up payments to their nursing home business. Enny Portillo of Highland Mills, NY plead guilty this week to nabbing $75k for personal care services that were not performed. Mrs. Portillo took advantage of NY’s Consumer Directed option to pilfer the cash. Corey Werito and Rosita Toledo (both awesome, and rhyming names!) of Farmington, AZ plead guilty of stealing $2M from Medicaid using their transportation company. Kester Atumonyogo (what is it with the awesome names this week?) of Valley Stream, NY stole $1.5M from Medicaid by using false claims to get paid for enteral nutrition supplies. Mr. Automonyogo- you win, even beating out the team effort by the group in AK! This week’s Roundup Fraud total – $4.6M from taxpaying citizens. And remember – that’s just what I found in the news quickly. At 4AM.

 

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 (I have 100+ pepper plants already.) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: hoouna mai ka Makua i ke Keiki e hoola i ko ke ao

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2lRoz5n

Or you can click the one for optimist readers –  http://bit.ly/2lRbJno

 

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 3^rd 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 clay@mostlymedicaid.com 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: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Uba ya aiko Ɗan ya ceci duniya

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

Or you can click the Special Valentine’s Day treat for optimist readers –  http://bit.ly/2lyalTX

 

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 9^th 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 clay@mostlymedicaid.com 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: http://eepurl.com/ep81Y . 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

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

Or you can click the one for optimist readers –  http://bit.ly/2irnjDt

 

WAIT A MINUTE- WHO’S SURPRISED AT THE CURRENT ACA REPEAL EFFORTS? It’s been hated by millions since day 1 (and loved by millions, especially on the left), the GOP has introduced 60+ repeal bills over the last 7 years – and now everyone is floored that one of the first things the Right does once it regains control is renew repeal efforts? The Senate took step 1 of a 10-step procedure to repeal ACA early Thursday morning. Here’s the best guide I have seen so far – http://read.bi/2ipCPji

 

THE LAND OF OPPORTUNITY STATE PUTS APPLICATION BACKLOG TO REST- AR brought in about 250 temp workers, but they got it done. Back in June there were 100,000 “pieces of paperwork” overdue, including 34,000 or so apps that were 45 days old. At year end (just a few weeks ago – weird), there were no overdue apps. Hey AR – can you send those temp workers over to KS?

 

SOONER STATE MCD NEEDS ANOTHER $200M TO KEEP THE LIGHTS ON- My crystal ball says they will get it. Just look at last year- when the overall OK budget was $1.3B short, OK Mcd got $1B (which was an increase over the previous year). You silly lawmakers need to just submit to the Mcd dominance of your budgets and move on.

 

MAGNOLIA STATE NEEDS ANOTHER $75M NEXT YEAR- Backers of the bump point to cuts in prior years, as well as a recent $58M cut in September that addressed lower-than-expected state revenues. It is interesting that the request for more money is happening when MS enrollment is decreasing.

 

KUDOS TO HPP ON THE KEYSTONE WIN- Health Plan Partners was awarded new membership  in PA this week. The award will expand the HPP PA footprint into 13 more counties, home to nearly 500,000 Mcd members. Congrats HPP!

 

THE COPPER STATE ANTI-EXPANSION LAWSUIT MOVES FORWARD- Its only been four years of spending money on the 300,000 new bennies, but the AZ Court of Appeals has scheduled the hearing challenging whether the way the Good Guvn’r Brewer unilaterally expanded was legal in the first place.

 

 

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.  Family Care Nursing (such a wholesome name!) of Meriden, CT settled this week for $5.3M related to billing for 60 day assessments knowing it was not an RN doing the work. Aretha Derrico was arrested for billing Mcd for $57,000 of home health services not provided in Havana, FL. Randy Crowell of Henderson, NV plead guilty to a $100M Rx reverse-diversion scheme last week. Mr. Henderson had an impressive range – from Utah to NY. How did he do it? He was a licensed wholesale rx distributor, of course. Still wondering what “reverse-diversion” means (I made that up, I think)? Instead of the pills going from legit sources to the black market, Mr. Henderson acquired pills in the black market and sold them to pharmacies. Sort of like money laundering, but with oxycontin. Although the specific hit to Mcd is not enumerated, I am more than impressed with this one. There are wonderful details like the use of lighter fluid to remove labels from bottles. Mr. Henderson – you win this week’s award! I would be interested in acquiring the movie rights to your story, when you get out of the slammer.

 

 

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 your pepper seeds. They will need 30 days to germinate, and then that’s March and you want them strong when you put them out in May, right?) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Pitā sēva dha varlḍa dīkarānī

Soundtrack for today’s RoundUp pessimist readers- https://www.youtube.com/watch?v=9jK-NcRmVcw

Or you can click the one for optimist readers –  https://www.youtube.com/watch?v=cYrUW68kggg

BONUS Optimist Song: https://www.youtube.com/watch?v=btPJPFnesV4

 

SOMEBODY TELL THE GOOD GUVN’R HE’S WEARING LAST YEAR’S FASHIONS: Perhaps the protracted battle with the outgoing Guvn’r has left NC Good Guvn’r Roy Cooper a little confused. He is talking about expanding Mcd in the Tarheel State, seemingly unaware that expansion is yesterday’s news. He promised to submit a state plan amendment by this Friday to expand under ACA rules, which have to be approved by CMS. This is either a PR stunt only, or the new Guvn’r is more clueless than the average bear.

 

NOW THERE’S AN IDEA: AK ASKS TO KEEP ACA CASH FLOWING BUT WANTS MORE CONTROL ON LIMITING ELIGIBILITY THAN ALLOWED BY MASTERS IN THE DISRICT (CAN I USE 2 COLONS IN A HEADLINE?): The Good Guvn’r Hutchinson has been in talks with the new cabinet members about letting AR tighten eligibility requirements for its expansion bennies. He may end up getting what he’s been begging CMS for for years after all. Amazing the difference a new king (er, President) makes.

 

AND SO IT BEGINS- One half of the country seems to be moving into the next phase of grief. The denial phase was like watching a train wreck- fascinating (Stein’s stratagem and the attempts at electoral mutiny), terrifying (Fake News pots calling kettles black) and pitiable (b-b-but the Russians did it!) all at the same time. We are now witnessing the negotiation and acceptance phases best I can tell. I now see Op Eds discussing how block grants may not be that bad (as long as its tied to healthcare inflation) and detailed analysis of the expected GOP battle plans to repeal the sacred cow of ACA (as opposed to the previous stance of “but they can’t do that).

 

KS ELIGIBILITY APPS: STILL LATE- 2 years and counting for the backlog. State officials did get it down to 1,400 or so in September (from a high of 15,000), but its climbing again. The latest number is 2,247 apps at least 45 days old.

 

MCO TIDBITS: Item 1) WellCare completed its acquisition of Care1st of AZ this week, adding 115,000 lives to the ledger. Item 2) Iowa newspapers are now reporting they have obtained secret documents showing MCOs calling the Iowa program “drastically underfunded” and a “catastrophic experience.” Sensing that these documents reveal a disconnect between what is being said publicly and privately, Mr. Pin Ochio has stepped in with new evidence that Oceania hacked the Iowa Medicaid agency. He insists we ignore the contents of the documents and focus on the manner of their discovery.

 

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. There’s actually just one this week: Abe Freund, operator of Acacia Mental Health Clinic, LLC in Milwaulkee has been charged by the feds with stealing as much as $7M from Medicaid. Acacia was billing $474 for drug tests that should have been paid at $20. At the end of the feeding frenzy, 99% of all Wisconsin substance abuse counseling payments were going to Acacia. Acacia payments surged from $300k to $3M over a few years. Lesson learned (?)- when you see 99% of your SA payments going to one provider that’s grown tenfold in a few years, maybe you should have something in place to stop paying that provider number before it gets to that point?

  

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 snow! One Yankees nuisance is a Southerners magical experience) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: o Patéras ésteile ton Yió gia na sósei ton kósmo

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

Or you can click the one for optimist readers –  http://bit.ly/2gUFq0R

 

MAKE MEDICAID GREAT AGAIN- I have had clients and readers ask my thoughts on what President-elect Donald Trump’s shocking (gasp!) victory means for Medicaid. I have intentionally waited a few weeks for the dust to begin to settle.  You can read my thoughts here- http://www.mostlymedicaid.com/?p=1874

Since most of the Medicaid news in the past few weeks has been speculation over what the Trumpening means for Medicaid, I have reserved this week’s RoundUp for news summaries of other items.

BUT FIRST, A CORRECTION – An earlier RoundUp incorrectly listed the Good Guvn’r Brandstad as the Governor of Illinois. I have written it correctly at least a dozen times (he gives me lots of material), but the one time I get it wrong, I hear from Richard, Rob, Marni, Claudia and others who wrote in to Correct the Record. I love it when people write in, and I love it even more when they provide corrections. It means they are paying attention. Thank you, and everyone – keep me honest!

 

SPEAKING OF IOWA- MCOs playing in the Iowa statewide rollout continue to post loss numbers (in the press). Losses in the latest stories range from 18-25% for UHC, AmeriHealth Caritas and Amerigroup in the Hawkeye State. The Good Guvn’r Brandstad tossed another $33M in the MCO pot in October to help cover unexpected costs (especially Rx). Its not all dollars and sense, though- 25,000 members now are getting care coordination services, 230,000 have been engaged with health risk assessments and other outreach efforts and more than 2,000 have been taken off the waiting list for a DD program. Aren’t these smashing successes? Where are the advocates showering confetti and throwing a parade for the MCOs? Seems a bit one-sided to me. Sometimes the naysayers remind me of cavemen- “MCO bad. Me get angry. Me repeat tired arguments against MCOs and me ignore abysmal outcomes in fee for service.”

 

ARKANSAS STRUGGLING TO KEEP UP- About 28,000 Medicaid applications are in purgatory in the Natural State. DHS officials are still saying they can get them all done by year end (that’s now less than 3 weeks when you adjust for the impact of the Christmas break).

 

MEDICA MCO WALKS AWAY FROM MINNESOTA- About 300,000 bennies in the Gopher State will need to cut up their old Medica card (“Medica” is the MCO name, which is confusing, and looks like I dropped an “id” or an “re”). Medica says it will end up losing around $150M on 2016 Minnesota Medicaid business. Of course the party line is: ”The evil MCO is making too much money and got greedy.” Assuming they are not lying, can you blame any business for wanting to not lose money?

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. Deborah Brown of Warwick, RI will serve four years and pay $230k for billing for DME (incontinence supplies) not medically necessary. Gregory Dodds, a counselor in Camdem, AR was ordered to pay $250k for defrauding Medicaid. His counseling practice operated from inside the building for Camden’s “Connection International Ministries Church.” His excuse? Mr. Dodds needed to pay off student loans. Bernie – where are you? Riyad Altalla and his wife Muna Alnoubani pled guilty to using their home health company to steal more than $1M from Ohio Medicaid. The lovely couple from Ohio wins this week’s award.

 

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 (build a fire! And while you are at it, read London’s “To Build a Fire”) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: mamam moavlina dze gadarch’ena msop’lioshi

Today is Veteran’s Day. In honor of those who have served in our nation’s military, please take a moment to read about the brave men and women who protect us. I have taken stories of fallen servicemen and servicewomen from the site thefallen.militarytimes.com. This selection is in no way meant to slight veterans who did not fall in the line of duty, or who fell earlier this year (the LinkedIn character limits do not allow more than a few to be shown). Please pray for the widows, children, parents and friends of those so recently fallen.

 

Staff Sargent Matthew C. Lewellen. Killed November 4, 2016 in Jordan (7 days ago). Green Beret, 5^th Special Forces Group. Hometown: Kirksville, MO. Age 27.

 

Staff Sargent Kevin J. McEnroe. Killed November 4, 2016 in Jordan (7 days ago). Green Beret, 5^th Special Forces Group. Hometown: Tuscon, AZ. Age 30.

 

Staff Sargent James F. Moriarty. Killed November 4, 2016 in Jordan (7 days ago). Green Beret, 5^th Special Forces Group. Hometown: Kerrville, TX. Age 27.

 

Captain Andrew D. Byers. Killed November 3, 2016 in Afghanistan (8 days ago). Company B, 2^nd Battalion, 10^th Special Forces Group (Airborne). Hometown: Rolesville, NC. Age 30.

 

Sargent First Class Ryan A. Gloyer. Killed November 3, 2016 in Afghanistan (8 days ago). Company B, 2^nd Battalion, 10^th Special Forces Group (Airborne). Hometown: Greensville, PA. Age 34.

 

Staff Sargent Adam Thomas. Killed October 4, 2016 in Afghanistan (38 days ago). Company B, 2^nd Battalion, 10^th Special Forces Group. Hometown: Takoma Park, Maryland. Age 31.

 

Aviation Boatswainís Mate (Fuels) Airman Devon M. Faulkner. Died September 20, 2016 (52 days ago). Assigned to USS Wasp, forward deployed in the central Mediterranean Sea. Home: North Carolina. Age 24.

 

First Lieutenant Jeffrey D. Cooper. Died September 10, 2016 in Kuwait (62 days ago). Headquarters Company, 2^nd Battalion, 502^nd Infantry Regiment, 2^nd Brigade Combat Team. Hometown: Mill Creek, Washington. Age 25.

 

Staff Sargent Matthew V. Thompson. Killed August 23, 2016 in Afghanistan (80 days ago). 3^rd Battalion, 1^st Special Forces Group (Airborne). Hometown: Irvine, CA. Age 28.

 

Staff Sargent Christopher A. Wilbur. Died August 12, 2016 in Afghanistan (91 days ago). 1^st Battalion, 12^th Infantry Regiment, 2^nd Brigade Combat Team, 4^th Infantry Division. Hometown: Granite City, IL. Age 36.

 

Lieutenant Colonel Flando E. Jackson. Died August 4, 2016 (99 days ago). 194^th Wing, Camp Murray, Washington National Guard. Hometown: Lansing, MI. Age 45.

 

First Lieutenant Anais A. Tobar. Died July 18, 2016 in Southwest Asia (116 days ago). 4^th Aircraft Maintenance Squadron, Seymour Johnson Airforce Base. Hometown: Miami, FL. Age 25.

 

To any veterans reading the roundup today, thank you for your decision to protect me, my family and my way of life. Thank you!

To any of the fallen, you will certainly have much more joy at the feet of Jesus than reading my silly little RoundUp. Thank you.

To Paw Paw (Sargent Major Ott Cecil Farris, Marine veteran of WWII, Korea and Vietnam)- I miss you. We all do. We are all so grateful for what you did for us so many years ago. And we all look forward to seeing you again.

To Private William Robert Caddy of Quincy, MA, thank you for jumping on that grenade on Iwo Jima on March 3, 1945. You saved my grandfather’s life (and the life of another Marine pinned down under Japanese sniper fire). It was thus possible for my father to be born 4 years after that, me to be born 28 years after that and my first child to be born 31 years after that. Your sacrifice upon that grenade has had impact for 61 years and counting. You are in no way forgotten and never will be. I will tell my children of you and they theirs.

Thank a veteran today. Thank one tomorrow. Pray for one today. Pray for one tomorrow. Buy one lunch. Pull your head up from the cesspool of the 24 hour news cycle and do something to honor them.

And each and every day- Praise God you were born in a country worth dying for.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2eH0oQa

Or you can click the one for optimist readers –http://bit.ly/2eGXWZM

 

Millions in Academic funding Goes Away- I must admit even I haven’t seen this happen in Medicaid. VT has taken $4M from academic medical centers and given it to family doctors. The redistribution was required in a bill passed last session, and appears to be aimed at maintaining the higher primary care payment rates ACA made possible for 2 years back in 2012-2014.

(Illinois) Medicaid Again Gets Allocation increase- Whatever you think of The Good Guvnr’ Brandstad’s managed care strategy, you have to give him props for stick-to-it-ness. When the press just won’t stop criticizing your decision to move to managed care, and attack you for 2 years with every story they can? Add $33M more to the MCO budget this year and tell those journalists to shove it. Brandstad claims the additional spending is possible because managed care has been even more efficient than predicted, and he is still on track to deliver the $110M in annual savings he promised.

(Virginia) Medicaid Annual costs Go up Again- New numbers out from a VA budget groups shows FY 2017 going up $281M. That’s a 7% increase in Medicaid spending over last year. This upward adjustment comes roughly one year after the most recent update to the VA spending forecast, which also showed staggering increases (and a $1.5B budget gap). Can anyone guess what the go-to solution being touted by The Good Guvn’r McAuliffe is?

Managing Affordable (care act’s perception) Goes Awry- It’s just gotten so very hard to pretend like ACA is successful at doing anything besides reducing the uninsured rate. And somehow, John Q. Public has caught on that even that is not so impressive for a policy that forces people to get insurance via penalties. For easy reference, I have placed a few links to the most relevant stories to come out in the last week or so here, here, and here. To me, the funny thing is that ACA really just decreased access for all the people that already had insurance (via higher deductibles that have a clear cooling effect on seeking care). Looks like all the king’s horses (pundits) and all the king’s men (whackjob healthcare economists) couldn’t put poor ACA back together again. I would write more in depth analyses, but it is considered impolite/impolitik/crimethink in our little healthcare world to do so.

 Managed (care) Assessment Gets Adjusted- States that rely heavily on taxing MCOs to deal with budget boo-boos are struggling under the new federal rules that require they broaden (tax more types of managed care entities besides MCOs) or eliminate the revenue stream – good LORD I lost the verb in here somewhere. Wait, nevermind- its just a few words after “boo-boos.” Anyway, they are struggling. Ohio is a good example, with one county standing to lose $20M in annual funding. Kasich is promising a fix but not a lot of details yet. Some predict he could mimic what PA’s Good Guvn’r Wolf did last year, implementing a $13 pmpm “assessment” on all MCOs. So basically, use a different word for tax to keep the money flowing.

LOTS OF OTHER THINGS THAT JUST WOULDN’T FIT – I missed deadline for last week’s RoundUp, so the twitter feed is especially full this week. News from this week and last on there, including lots of fraud stories.

 

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 (go vote on Tuesday! The founding fathers bravely rejected the oppressive, corrupt rule of the elites of their day, and you can too) and keep running the race (you know who you are).

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FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Pai enviou seu Fillo para salvar o mundo

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2dUj8v7 ( bonus song- http://bit.ly/2dUhABf )

 

Or you can click the one for optimist readers – http://bit.ly/2dUJkFR

 

RUH-RO IN OR: Looks like OR Medicaid may be un-invited to all the nice parties again (for those of you that remember the scandalous Medicaid-coverage-leads-to-worse-outcomes stories a few years back). New, long term studies have confirmed that the 40% ER spikes seen after expansion are sustained. The “pent-up demand” theories that assured us it would go down after initial uptake were proven false.

SHOW ME STATE SHOWED US THIS WEEK: Who the new MCO winners are, anyway. Centene, WellCare and UHC – Congratulations! The new contracts include a significant expansion (adding 61 counties). Aetna lost out on this one – and lost 270,000 monthly cap payments as well.

HUGE PROPS TO AMERIHEALTH CARITAS OF PA- The MCO achieved what only 14 others did nationwide – a 2016-2017 NCQA rating of 4.5. Keep up the good work!

VIRGINIA IF FOR (DEFICIT) LOVERS- VA has a $1.5B deficit, resulting in layoffs, agency cuts and other measures. Despite all this (but of course he argues because of all this), the Good Guvn’r McAuliffe is nagging/lobbying for VA to expand Medicaid again. Trot out the “but it’s free money from the federal government – they get it from the money trees in DC!” argument. Thinking people know that its not free, and it does add hundreds of millions more in the state share of Medicaid costs.

GET THOSE WAIVER APPS IN QUICK, PEOPLE- Seems like CMS is thinking there might be some sort of change that impacts federal healthcare policy happen in November? Any idea what that could be? For waiver apps that are in line with CMS desires, there is a fast track lane. Case in point- WA just got preliminary (helps us have something to latch onto post-November) approval of a new $1.5B Medicaid reform waiver. The WA deal will include monies to revamp LTC (among other things, most of them focused on shifting to value based care and out of FFS). Now if you’re KY and wanting to dial back expansion, well you’re request somehow made it to the bottom of the pile.

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. “Dr” Stanley Marable plead guilty to Medicaid dental fraud in Valdosta, GA this week. He stole $789k from GA Medicaid for tooth extractions that didn’t happen. OmniCare, the largest institutional pharmacy in the U-S of A (it’s a nationwide nursing home pharmacy) has agreed to pay back $28M to various state Medicaid programs over allegations it conspired with Abbot labs in a kickback scheme to increase Depakote sales. Robert Novy, and elder-law attorney of Brick, NJ was charged this week for defrauding clients out of $1.2M. He presented himself as an elder advocate, “helping” clients navigate Medicaid financing issues (think estate recovery), but in reality he was (allegedly) taking control of their finances and stealing their savings. OmniCare- you win this week’s award. I would make some witty quip about seeing you in orange and in jail, but it seems like more and more powerful people / corporations are above the law these days.

 

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 a rain dance for AL- we need it!) and keep running the race (you know who you are).

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FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Isä lähetti Pojan pelastaa maailman