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Weekly Medicaid RoundUp: Week of September 5th, 2016

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2cz0jxc (this song is so depressing, but the video is important- pay attention to Amber alerts, people!)

Or you can click the one for optimist readers – http://bit.ly/2cyUfVy (Freddie still gives me goose bumps. And I still believe this song at every football game)

 

DO YOU REMEMBER WHERE YOU WERE WHEN THE TOWERS FELL? This Sunday will be the 15th anniversary of the terrorist attack on the United States that killed 2,996 people and changed the course of history. I was asleep on a couch in the Southside of Birmingham, Alabama. I got woken up with a phone call from my father telling me to turn on the TV. Where were you? Write in in the comments or send me a note. Never forget. Teach your children.

THE INVISIBLE HAND (THE OTHER ONE, NOT ADAM’S SMITH’S)- MA is looking to cap MCO provider payment rates at 105% of FFS rates. Hospitals in MA currently claim they get 76% of the cost of care (then go out of business already and get into something you can make money in, if you’re really taking those types of hits!) under the non-capped setup. The hospitals claim that the cap would bring payments down to 56% of the cost of care.

TOUGH COUPLA WEEKS IF YOU’RE IN THE DIALYSIS SPACE –  A few weeks ago CMS took a shot over the bow (in a well done RFI-way, if you ask me) at how some providers jimmy with insurance for dialysis members to get higher payment rates. This week saw the KY Attorney General Andy Beshear (somebody tell me he’s not the previous Guvn’rs son…) take a shot at Fresenius, saying they promoted a harmful dialysis product to patients.

SAY IT WITH ME: CON-SOL-I-DAY-SHUN- New numbers out this week quantify what we in the space all know: the vast majority of MCO-covered lives are in a handful of plans. Roughly 43% of all Medicaid managed care bennies have a card from one of the top 5 national MCO outfits.

SHOW ME STATE DOES SHOW AND TELL- Telehealth in schools, that is. The Good Guvn’r Nixon signed a law to allow schools to bill Medicaid for teleconferencing physician services for students. The new funding approval is expected to help students with speech / language therapy and behavioral health needs the most. Rural areas have had a particularly hard time getting these types of specialists out to schools.

 

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. Jesus Villegas of Milford, CT extracted (he’s a dentist) $1.4M in fraudulent payments by using non-credentialed assistants to run up x-ray tabs for MA Medicaid. Great Nursing Care of Reynoldsburg, OH nabbed $4.9M in Medicaid overpayments using less than qualified providers (I see a pattern) and billings for unauthorized services. Owners closed shop upon receipt of the auditor’s letter. Oh, well – what’s another $5M in taxpayer dollars that just vanished into thin air? That’s just a drop in the bucket, nothing to see here. Move along. CVS in MA has agreed to pay Medicaid $800k for being so terrible at monitoring drug seeking behavior for opioid addicts (there was a system that tracked this, but CVS did not give its pharmacists access to it). Mr. Villegas, you win this week’s award. Awesome first name, by the way- but you do it dishonor.

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 (temps are dropping) 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 | de Vader de Zoon gezonden om de wereld te redden

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Weekly Medicaid RoundUp: Week of August 29th, 2016

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2c6pb2c

Or you can click the one for optimist readers – http://bit.ly/2ahXf8T

A BETTER WAY TO LOOK AT FRAUD IN MEDICAID- RoundUp readers and now show watchers know I can’t stand it when people essentially defend the huge disgrace of Medicaid fraud with the “I know its billions but that’s just a drop in the bucket in overall spending” or “but there is fraud in commercial and in Medicare, too!” A great article coming out of Illinois makes the (obvious) connection between Medicaid fraud (which we look the other way on) and Medicaid cuts (which we go bonkers about). Guess what- if you lose $12M on payments for dead people, you may have to cut some provider rates next year. (That article actually follows one family with a child who was counting on services and was directly impacted by Medicaid cuts that had to be made in part because of some large fraud losses). In other news, CMS released data on the improper payment rate for Medicaid (fancy way of saying fraud and stuff we can’t exactly call fraud). 2015 was 9.8% – that’s right, 10% of all Medicaid payments are “improper”, even by CMS’s own numbers – and it is projected to be 11.5% for 2016. For comparison, 2013’s rate was around 5%.

DON’T LOOK AT THIS CUP OVER HERE, LOOK AT THAT ONE OVER THERE! It was a rough month for ACA. The news of way higher than expected pmpm costs for those “healthier” expansion bennies was a punch to the gut, and the news of mass exchange exodus by the plans (I’m looking at you, Aetna) was the subsequent uppercut to the chin while ACA was bent over from the gut punch. Keep in mind some of the smartest people on our planet are investing their entire careers in ACA, so damage control was impressive (related vocabulary word – “sophistry”). Still hard to cover up some it, though. My favorite last week was an article that claimed expanding Medicaid keeps premium rates down on the exchanges. It’s a garbage argument, but works if you don’t ask too many questions. On a more positive note – if you are not following Slavitt on twitter yet, you need to. The head of CMS is tweeting constantly, and he’s honest, brilliant and engages people who disagree with him respectfully.

RUH-ROH IN ALASKA- After the fun sideshow that we all got to watch with Alaska’s expansion drama last year, a completely unexpected thing has happened. Expanding Medicaid has cost AK $30M more than projected. AK is now in the first stage of grief (denial), so consultants are trotting out the same old worn-out consolation theories: pent-up demand (previously known as the “woodwork” effect, until someone realized that was sort of a rude way to put it), costs will go down next year, et cetera.

KEYSTONE STATE SELECTS MLTSS MCO WINNNERS (FINALLY!)- Judging from all the calls I got on this one, a ton of RoundUp readers have been watching the procurement. Winners were AmeriHealth Caritas, Centene, and UPMC for You. 14 total bidders gave it a go, so expect some protests. In the meantime, congrats to the winners!

OK MEDICAID DIRECTOR LEAVING- Nico Gomez announced plans to leave the agency this week. Gomez has been at the helm during one of the toughest chapters in all of Medicaid history, with a particularly challenging budget reality in OK. Good luck, Mr. Gomez! Let us know where you end up.

 

FARRIS’S FANTASTIC FRAUD FOLLIES– Just not enough space this week. A few good ones in the twitter feed. Head on over there and get your fix.

 

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 (leaves are starting to change) 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 | Otec poslal Syna, aby zachránil svět

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Clay’s Weekly Medicaid RoundUp: Week of August 1st, 2016

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

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

THE HEART OF IT ALL STATE WANTS BENNIES TO PUT SOME CASH IN THEIR PIGGY BANK- Ohio wants bennies to put the lesser of 2% of their income or $8.25 / month (or the cost of about 1.5 packs of cigarettes, which would get a chain-smoker through about 4PM one day) into a health savings account (which would be mostly funded by the state). Ohio number crunchers say the plan would save about $1B over 5 years compared to current spending. Whoa! A Medicaid “savings” number that means less actual dollars spent? Not some crazy “but we would have spent more if aliens landed and all enrolled in our program, so this plan “saves” money” savings estimate? The real kicker – bennies who can’t cough up the $8.25/month would be disenrolled. I give this 1 snowball out of 5’s chance (in Hell) of CMS not laughing this out of town.

 

KEYSTONE STATE CONTRACTS KINKED-UP OVER PROTESTS- All those new MCO contract awards we’ve all been watching the last 18 months in PA? Yeah, not gonna happen anytime soon. The latest round of implementations was supposed to start Jan 1, but a judge sided with Aetna this week on a move to delay until April. Aetna protested part of the state’s proposal review methodology. Now bidders have until August 22nd to submit proposals under the restarted RFP process.

 

EMPIRE STATE OF THE SOUTH TELLS PROCUREMENT PROTESTORS TO STUFF IT- GA officials let the losers have their say (Americhoice, Humana and Amerihealth Caritas), but in the end said “no thanks, you still lose.” The new GA CMO (That’s an MCO everywhere else except GA) contracts were supposed to start this month, but now are delayed until at least August 2017. Losing MCOs can still take it to the courts if they want to (the current protests were handled by the state Dpt of Administrative Services).

 

AUDITOR TURNS OVER ROCKS IN OLD NORTH STATE, FINDS (INFERS) UP TO $17M IN NO-NO PAYMENTS FOR DME- For audit geeks nationwide, NC has been a hit parade of sorts the past few years. And the hits keep on coming. Beth Wood (the state auditor) took a national estimate of DME fraud rates and applied them to NC Medicaid claims to come up with the potential NC loss. Then she reviewed NC DMA payment review policies and said they weren’t up to snuff. A PCG post-payment review contract was also cited as an example of poor vendor management (per Wood, NC DMA staff did not do any verification of the PCG results).

 

NOT THAT ANYONE’S WATCHING, BUT BLUE-GRASS STATE EVIL PLAN TO ROLL-BACK EXPANSION MISSED FIRST DEADLINE- The Good Guvn’r Bevin’s office missed an internal deadline related to submitting its infamous 1115 waiver to CMS this week. Reason cited? Way more comments than expected.

 

CONGRATS DUE TO ADVANCEMED- They just want a $77M contract from CMS to provide fraud consulting. Congratulations!

 

WELLCARE BOOSTS M&A TEAM- Tuesday’s earnings call was encouraging for those of us excited to see the WC comeback into the Medicaid space continue. CEO Ken Burdick focused on criteria for targets in both the Care’ and Caid’ spaces (and largely avoided speculation around the WC role in the event of a breakdown in the Anthem/Cigna deal).

 

FARRIS’S FANTASTIC FRAUD FOLLIES– Just not enough space this week. Plenty in the twitter feed, I promise. Head on over there and get your fix. My favorite this week is probably either the St.Joes story or the Tenet one.

 

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 got lemongrass plants on clearance for $1 this week!) 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 | Otac je poslao Sina da spasi svijet

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Clay’s Weekly Medicaid RoundUp: Week of July 25th, 2016

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2aeAX7r OR http://bit.ly/2aeAGBD

Or you can click the one for optimist readers – http://bit.ly/2aeB57a  OR http://bit.ly/2aBPHRo

 

SUCH A HISTORIC WEEK – Unless you have been under a rock (or perhaps engrossed in your Pokemon Go! adventure), you know this week saw a very historic milestone for our nation. Yes, dear readers, I am of course referencing the fact that a single healthcare fraud topped $1B for the first time ever.

 

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. Philip Esformes of Miami has set the world record with his $1B fraud robbing taxpayers who fund Medicaid. Esformes used his 30 nursing homes to bill for unnecessary procedures for Medicaid bennies. $1B people- $1B!! That’s 15,384 teachers (at an average annual salary of $65k). Heck, that might even cover 1 month of ACA premium increases. Staying in Miami for a moment, Fernando Mendez-Villamil was sentenced for 12 years for defrauding Medicare and Medicaid out of $50M. How did he get caught? At some point, he got on Chuck Grassley’s radar who noticed Mendez-Villamil wrote 96,685 scripts over 2 years for Medicaid bennies alone. Let’s head northeast to Chicago, where Gregory Toran was convicted of stealing $4.7M from Illinois Medicaid using his transportation company to bill for rides for dead people and for live people who never actually took rides. Now lets’ go way northeast on up to Anchorage, AK, where Mee Chong Collins stole $320,336 from Medicaid using false personal care services claims filed under her “Sunshine Care Services” company. Let’s move back towards the heartland, where Wendi Baker of Tiffin, OH was indicted for stealing up to $300k from Medicaid while working as a nurse at Blanchard Valley Health System. Hop on over to Oregon with me, as we watch Anthony Neal plead guilty to stealing $1.7M from Medicaid by using his clinic to order unnecessary tests. Total RoundUp reported fraud tab this week (not including the historic $1B from Mr. Esformes): $57M. Of course, Mr. Esformes, you win this week’s award!

 

WOW, JUST WOW- So much happened in the fraud space last week (much of it likely tied to another one of those coordinated drag nets we’ve seen the past few years), its almost difficult to think of much else. In the spirit of innovation, I will leave you with the rest of this week’s Medicaid news, in traditional haiku form (5-7-5):

 

News Item 1

Supplemental rule

Leaves OMB, goes to Prez

Cash this way rising

 

News Item 2

Bad times for Alere

Investigation slows buy

Kickbacks, fraud – oh my!

 

News Item 3

BlueGrass state looks back

Before leap, before Beshear

Plays chicken with feds

 

News Item 3

Public option lives!

Policy wonks remember

Prez gave C-P-R

 

News Item 4

Wolverine State plans

In the money, man oh man!

ACA cap rates high?

 

News Item 5

Brandstad marches on

Tells Dems and press to stuff it

Growing pains, he says

 

News Item 6

Anthem beats forecast

CIGNA deal still taking time

But rolls grew half-mill

 

News Item 7

UHC, Aetna

New Cal-forn-ya MCOs

Congrats on the win!

 

News Item 8

Caid’ Rx report

Abilify, Sovaldi

And Vynase top list

 

 

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 time to start planting a second crop!) 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
lu Patri mannau u Figliolu di salvà u mondu

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Clay’s Weekly Medicaid RoundUp: Week of July 18th, 2016

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

Or you can click the one for optimist readers – http://bit.ly/2ahXf8T

 

ACA COSTS WAY MORE THAN EXPECTED/ADVERTISED? YOU DON’T SAY? Those meanie right-wingers over at Forbes just keep insisting on holding federal officials accountable to their cost projections for ACA. Per Forbes analysis this week, HHS 2015 ACA per-enrollee projected costs were off by 50%. While HHS said new ACA bennies would cost $4,281 per year, they actually cost $6,366 per year. Cue leftist explanatory gymnastics (but whatever you do, don’t suggest that government officials are either unable or unwilling to estimate the true costs of what they are proposing even as little as 1 year out).

 

BUT WE WANTED IT TO BE OUR IDEA! In NC, a huge push for Medicaid overhaul has been going on for a few years, and the state recently submitted an 1115 to CMS to bring managed care to the state. Now left wingers are directly pleading with CMS to reject it, arguing that the current Medicaid system in NC is just fine. Read between the lines and you will see that managed care is expected to reduce costs (payments) in NC Medicaid (which have been wildly unpredictable the past several years) and threatens the future of CCNC (a valuable – but also politically powerful – vendor of provider EHR and care coordination services).

 

ANOTHER EXPANSION TRIAL BALLOON IN TN LEGISLATURE- Volunteer State House Speaker Beth Harwell is getting back on the bicycle to try yet another flavor of expansion. This time she is hoping a focus on vets and mental health will be the push that expansioners need to get a plan passed.

 

CMS TO UTAH: “TALK AMONGST YOURSELVES” If you’ve been following the planned UT expansion here in the RoundUp, you know it’s a pretty focused approach – chronically homeless, in the justice system or needs MH/SA help. So CMS will be very careful with this one, and this week they asked UT to get some more public comment in their state before CMS reviews (and opens their own public comment period). CMS has specifically noted that the budgetary portion of the proposal was not finished when the UT public comment period ended. My guess is they won’t get any “aha moments” from extended comment, but it will be interesting to see what the “input” from the public is on the costs. “You’re spending too much on this” – said no Medicaid bennie or advocate ever.

 

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. Ted Suhl of Little Rock, AR got convicted of bribing a Medicaid official this week. Seems Mr. Suhl paid off AR DHS Deputy Director Steven Jones (who plead guilty last year) to make sure Suhl’s mental health companies got $90M in Medicaid moo-lah. Cynthia Harlan of Charlotte, NC was convicted this week for her role in a $10M services-not-provided scheme. Paul Mil of Springfield, NJ is headed to the big house as of Thursday. Mr. Mil nabbed $7M of your tax dollars using a bogus home health Medicaid scheme (unqualified providers, fake claims – surely, and sadly, you can fill in the rest of the sentence by now dear RoundUp reader). Patricia Torrington of Bridgeport, CT was sentenced for $1.6M in bogus Medicaid psychotherapy services.  Mr. Suhl – you win this week’s award by a landslide! Maybe you and Mr. Jones can be cell mates? I’m sure he will remember you as a friend for all those bribes you paid him when he was a state government employee. (Lots of honorable mentions for the follies in the twitter feed this week, folks).

 

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 maybe stay in- its HOT!) 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

Fùqīn sòng érzi lái zhěngjiù shìjiè

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Clay’s Weekly Medicaid RoundUp: Week of July 4th, 2016

Clay’s Weekly Medicaid RoundUp: Week of July 4th, 2016

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/29zczxr

Or you can click the one for optimist readers – http://bit.ly/29FFLFP

Hope everyone had a great 4th of July. For all you folks educated in the public school system in the last 20 years, let me help you out with a clear telling of what happened 240 years ago. The 4th of July is when we celebrate some of the best men ever to have lived declaring that we would be ruled by laws, not corrupt tyrants. It is not about hot dogs or fireworks – but you do get to enjoy those things because awesome men called “the Founders” started something called “America.”

VOLUNTEER STATE ROLLING OUT HEALTH HOMES IN 4 MONTHS- TN’s Health Link program will serve behavioral health members by coordinating their primary care and behavioral health care (that whole integrated care thing). Providers will get a monthly cap for the coordination service between $70 and $140.

NO DICE FOR NO-SHOW FEE IN SHOW ME STATE- Doctors in MO are taking a hit with a high missed appointment rate for Medicaid bennies. So they wanted to have a fee imposed to members- $5 for the second missed visit, $10 for the third, and $20 for every visit missed after that. The Good Guvn’r Nixon vetoed the bill, saying it would be “gouging the poor.”

BUDGET WATCH- KS hospitals are phoning-a-friend (the federalis) to try and stop cuts enacted to deal with the budget deficit. In an open letter to CMS, the KS Hospital Association pleads with the feds to stop the $54M in cuts that would hit hospital pockets. AL docs will see the primary care payments boost come to an end starting this month. As part of AL’s $85M budget shortfall, the Medicaid agency decided to stop enhanced payments enacted originally using ACA one-time monies.

EXPANSION WATCH- AR shot its revised expansion plan over the bow this week, complete with a list of evil, access-killing requirements. If approved, the new gig will send unemployed bennies to work training programs, end 90 day retro eligibility, provide dental for bennies who pay their premiums and require bennies between 100 and 130% FPL to pay a premium that’s no more than 2% of their income (what % of your income is your premium, dear reader?). Move over west just a little, and the Good Guvn’r Bevin (KY) and CMS are now in talks over his plan to change expansion in the state. Bevin has rolled out new rules related to work requirements (including an allowance for community service) and encouraging transitioning from Medicaid to commercial insurance. According to Bevin’s team, the changes will save the state about $331M over five years. Bevin wants approval by September; CMS is saying there’s no rush in reviewing the request. If you read between the lines, Bevin is sort of saying to CMS – accept these changes or we un-expand. I like it.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Seven DE DHHS case workers were indicted for stealing $959k in food stamp benefits. “Drs” Chethan V. Byadgi and Rajaa Nebbari of Scranton, PA got their plea deals rejected last week- their crime? Allowing non-licensed staff to write scripts for narcotics and filing $159k in false claims to Care’ and Caid’. “Dr” Monaco of Haverford, PA operated A Foot Above Podiatry and stole $5M via false claims (services not provided). Misty Baker of Brandon, VT stole $77k using faked time sheets for the VT Children’s Personal Care Services program. Wow, what a diverse week we had for fraud! We even had a nearly $9M foodstamp fraud in our lil’ ole Medicaid column. That being said, you can only win if your fraud is for Medicaid (and at least $50,000 – to weed out the amateurs). “Dr” Monaco – you win this week’s award!

A WORD ON OUR WEBSITE- To all those who visited our site the last few weeks, you may have experienced downtimes and malware warnings. We have just completed a relaunch with a new hosting provider, and should be good to go. I apologize for the inconvenience. I promise we are not Estonian hackers trying to get your SSNs. Although there probably are some of those doing just that right this moment- in order to file false Medicaid claims, of course.

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 tomatoes are coming in!) 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

hkamaeetawsai kambhar  kaalhphoet  sarrtawko hcay lwhaattaw muu

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Clay’s Weekly Medicaid RoundUp: Week of June 6th, 2016

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/1UGzggU

Or you can click the one for optimist readers – http://bit.ly/1UGznci

BEAVER STATE 1115 ON SCHEDULE- Oregon will be submitting more of a continuation waiver than major changes for its Care Coordination Organization (CCO) model. The first major report on the CCOs for the state will be July 1 this year, with the waiver renewal application timed for late summer. According to the Good Guvn’r Brown, she wants to get it approved before the White House changes hands. Maybe she knows something we don’t?

BUCKEYE STATE GETS NOD FROM THE BIG HOUSE- Ohio just got CMS approval for their plan to move nursing home residents back into the community. OH has been doing this already, with 8,000 residents driving away in a U-Haul with crying nursing administrators staring at tail lights.

NATURAL STATE ADDS 25,000 TO THE ROLLS SINCE FEB- Despite all the legislative brinksmanship this spring, AR still found a way to grow the expansion rolls to 290,000.

SOONER STATE DOCS DODGE A BULLET- It was dire and desperate in OK up until last week. Medicaid providers faced a 25% rate cut. But somehow, magically – no miraculously – state legislators were able to give Medicaid $99M more this year compared to last. Amidst a $1.3B state budget shortfall. I truly am in the right line of business. Medicaid, you need way more money every year? Sure thing! Education, roads, everybody else – sorry!

PEACH STATE WARMS UP TO THE SUGAR MONEY- State Senator Renee Unterman shot down ACA expansion cash, but is now suggesting (on the state senate floor) that GA should consider doing an 1115-style expansion instead.

HOOSIER STATE CLAIMS “THE TEACHER DOESN’T LIKE ME”- IN got an emergency approval of its “conservative” (reads – not nearly as far left as the administration likes) Medicaid expansion plan this April. Now CMS is surveying members to see how they like the “conservative” approach, and IN says the surveys are biased against their model. And it sort of matters beyond IN – states like AZ, KY and OH would like to get them one of those new-fangled “conservative” Medicaid expansions, too. Who knew Medicaid could be so political? I thought it was just healthcare, right? The main Hoosier complaint is that there are plenty of questions about why you might be dissatisfied with the plan, but none asking why you are satisfied with it. Apparently question #17 had some rattled. The survey question reads: “Are you now, or have you ever been, a member of the Republican party?”

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. Barbara Sadler and Sedric Blakes of “Extraordinary Care Network” were convicted on a $1.2M Medicaid fraud charge this week in Baton Rouge, LA. Their crimes? Billing for one on one therapy that didn’t happen, forging signatures and fabricating client progress notes. Jennifer Green and Andria Jones of Jackson, MS got popped this week for a $1M fraud in which they got paid for bogus counseling claims. Candia Tolbert, who operated “No Child Left Behind Behavioral Health Services,” was convicted this week on $100k for false claims. Congratulations Barb and Sedric – you win by a hair, just barely beating out Jennifer and Andria.

REMINDER – NO STATE SPOTLIGHT SHOW THIS MONTH, BUT STILL DOING THE NEWS ROUNDTABLE SHOW– I know people plan their weddings and other things around those, so just trying to get the word out.

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 sun is up earlier now!) 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

Otets prati Sina , za da spasi sveta

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Clay’s Weekly Medicaid RoundUp: Week of May 31st, 2016

Back from one of my infamous breaks. One of the interns told me that CMS passed some sort of “Mega Rule” while I was out. That doesn’t sound too terribly important, so we’ll skip it for today.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/1ZiOmgC . Trust me, its cool. Click it. You know you want to. Or you can click the one for optimist readers – http://bit.ly/1ZiOwEI

As is our custom here in RoundUp Land, when returning back from a break, let’s start with the red meat.

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. Florence and Michael Bikundi of D.C. just got sentenced for the largest ever Medicaid fraud against the District – a whopping $80M over 5 years. They used their home health company – Global Health Care Services – to enrich themselves and relatives by paying Medicaid bennies kickbacks for lying about claims for services not provided. Edward and Contina Foxx of Bedford, VA got sentenced this week for bennie fraud. They received $80k of Medicaid benefits but failed to report $500k in income they got from their scrap metal business. Mary Ann Stewart (such a wholesome sounding name, amiright?) of Pittsburgh is going to the Big House (not CMS, the other one) for operating a bogus hospice. She nabbed $500k from Medicare and Medicaid by admitting members who weren’t actually terminally ill. But doesn’t hospice require a doctor saying you need it? Yep – “Dr” Oliver Herndon helped Mary Ann out there with bogus claims. He got 3 years for his part of the fraud. “Dr” Naimetulla Syed of Newtown, CT got popped for $400k in upcoding Medicaid psychiatric claims. Seems he liked to bill for 45 minutes of therapy but only deliver 30 minutes. A housing and assistance company that serves DD members in Middletown, CT has to fork over $1.5M for falsified cost reports. Mobile Pharmacy Solutions of Buffalo, NY has to pay Medicaid $442k for filling scripts for a barred doc (“Dr” Mikhail Strutsovskiy). Still in the Empire State – Andrew Barrett, a pharmacist from Queens, pled guilty this week for $2.7M in bogus HIV meds scripts. And finally, “Dr” John P. Moore the 3rd (I imagine him with a monocle and cigar, much like Thurston Howell the 3rd on Gilligan’s Island) was sentenced to 20 months in the slammer for $80k worth of Medicaid fraud. His rap sheet now also includes drug trafficking, theft and permitting drug abuse. Phew! A lot happens in a few weeks’ time. So many to choose from… This week’s award goes to the 2 lovebirds in D.C.-  Mr and Mrs Bikundi – enjoy your stay in the jailhouse. Maybe you can get the Honeymoon Suite?

OFF ™ SALES TO SKYROCKET AFTER MEDICAID COVERAGE- Zika is our latest microscopic enemy, and the federalis just approved Medicaid cash for Mosquito repellant.

THE LEVEE BREAKS- The Hep C rx spending tsunami is set to obliterate already anemic state budgets after a string of lawsuits (and threatened lawsuits) felled any remaining speed bumps in several states last week. FL and WA both announced less restrictive coverage policies, and PA is on the brink of falling in line.

IF ONLY I KNEW A WELL-CONNECTED MEDICAID ENTREPRENEUR- The Big House (CMS, not the other one) knows it needs some innovation from the private sector and is reaching out. Its doing a road-show with tech firms (Slavitt went to Silicon Valley this week) trying to gin up some techie brain power. They also have a sort-of job posting for a “well-connected entrepreneur” to serve as a “Sherpa” to help tech companies get to know Medicaid. Anyone ever met one of those?

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 sun is up earlier now!) and keep running the race (you know who you are).

—-

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News that didn’t make it and sources for those that did: twitter @mostlymedicaid

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Clay’s Weekly Medicaid RoundUp: Week of May 2nd, 2016

BUCKEYE STATE ON FOOLS ERRAND- Ohio has the laudable, but laughable, goal of implementing a requirement that Mcd bennies chip in $99 bucks (or about 1.5 cartons of Marlboro Reds in Ohio) a year. The member contribution would go to a health savings account. There would also be new copay requirements (the state would dump a grand into the HSA to help with those). I give this less than a 5% chance of passing given the “your-evil-for-even-suggesting-there-be-the-slightest-cost-to-the-member” mentality of most of those in our Mcd world.

EMPIRE STATE CONSIDERING MCD COVERAGE FOR EX-CONS- The Good Guvn’r Cuomo is horse-trading with CMS as we speak to get Mcd funding for the plan. His plan appears to be a limited scope benefit, designed to help with substance abuse and a defined set of medical conditions.

UPDATE ON AL MCD USING BP OIL MONEY FOR FIX- It didn’t happen. Seems that some state senators wanted to use the money AL got to deal with the coastal disaster on roads instead of Medicaid. Officials are now foreshadowing the areas to be cut the most. It’s getting hot down here, and its not even June.

SUNFLOWER STATE SLOWS DOWN ON WAIVER INTEGRATION PLAN- The Good Guvn’r Brownback of KS will not veto a legislative directive to stop efforts on the integrated waiver services for Kansans with disabilities. The planned waiver was aimed at increasing HCBS services for members, but advocates were concerned of the speed and ambiguity of the plan.

WE DID NOT THINK OF THE IMPACT OF THE MINIMUM WAGE HIKE ON MEDICAID COSTS, COMRADE- When NY decided to raise its minimum wage from $9 to $15 by 2018, seems no one did the fiscal impact analysis on Mcd costs. As we in our insulated, behind-a-computer-or-on-a-plane-each-week jobs often forget, the healthcare industry employs many minimum wage workers. This provider increase (the wage hike) will add $13M to this year’s NY Mcd costs and $88M to next year’s. And the year after that, and the year after that . . . No worries. Close your eyes and remember the money trees in Washington, D.C. They’re so pretty this time of year.

LOTS OF LITIGIOUS PAYDAYS FOR STATES- Lots of cash flying around this week, mostly from big pharma to states. KY got $5M from Pfizer related to drug rebates not paid on Protonix (an antacid drug – [INSERT HEARTBURN JOKE HERE]). IN got $9M from the same lawsuit. WA got $23M. Total payout to all states and federalis was $784M (ouch, Wyeth. But at least you can move on and watch the stock price rise now that the settlement is done, right?).

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph.   Wayne Wilson of Statesville, NC is headed to the big house for 18 months for stealing $210k for services he did not perform. Wayne is a doc who thinks Mcd didn’t pay him enough, so he “padded” his claims. Dwight and Charmetra Reece (man, there is a lot of husband and wife Mcd fraud) of Oklahoma City were charged this week with stealing $99k from Mcd. The couple operated a counseling agency and billed for services not delivered. Including payments for Charmetra’s mother (who is not a licensed counselor). Agape Health of Alexandria, VA has settled with Mcd this week over allegations it billed for transportation services not provided. Total bogus cab fare – $386k. Agape – you win! Follow that cab! (to jail. Do not past Go.)

I CAN’T NOT WRITE ABOUT THIS- George Clinton will release a new album this year entitled “Medicaid Fraud Dawgs.” I am not making this up.

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 sun is up earlier now!) 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

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Clay’s Weekly Medicaid RoundUp: Week of April 25th, 2016

BRITISH PETROLEUM TO FUND AL MEDICAID- Lawmakers struggling to scrounge up funds to fill the Mcd budget gap have come up with a way to leverage money the state is owed from the BP oil spill. It’s a little tricky for me to understand but it involves a bond issue that then gets paid off with BP money and I think somehow a new (or quicker) $85M pops out to plug Mcd. Not sure yet on the reaction from coastal residents who may see the move as snatching the funding tied to the devastation of their environment six years ago.

EMPIRE STATE TO COVER HEP C DRUGS- This follows a recent lawsuit requiring commercial plans in NY to cover drugs like Sovaldi and Harvoni. There are 25,000 new Hep-C cases in NY each year. At some point, each of those could become eligible for the drug, creating a new $2B annual spending item for Hep-C rx alone.

LA MEDICAID EXPANSION IS ROLLING OUT NOW- The state is beginning to migrate members from existing programs that already meet the Mcd expansion population requirements. Members of Take Charge Plus and New Orleans Community Health Connection were asked to update addresses this week so that they can receive their brand new Mcd cards.

AZ HOSPITALS RECEIVED MORE THAN $1/2B RETURN ON THEIR MCD “TAX”- The Medicaid Magic Money machine strikes again. St Joe’s had the biggest ROI on the “tax”, receiving more than $24M than it put in. The money trees in D.C. did look a little sickly last week, but they were watered and rebounded quickly.

MOUNTAIN STATE WILL GLADLY PAY YOU ON FRIDAY FOR A HAMBURGER TODAY- It’s never a good sign when the Mcd agency sends you a letter saying it may be a while before you get paid because state revenues are down. Yet that’s what WV did to 24,000 Mcd providers this week. At least they gave you a heads up, I guess?

MCO WINS IN THE KEYSTONE STATE- Centene and UPMC won bids in SE PA this week under a new effort to negotiate pay for outcomes MCO contracts (up to 30% of payments tied to outcomes). Congrats to our friends and colleagues in Centene and UPMC!

AH, THE MEGA RULE- As most of you by now know, the final Medicaid Managed Care Rule was released Monday. There’s simply too much to cover but 2 quick things- the already voluminous 653-page rule more than doubled itself to 1,425 pages (maybe they fed it after midnight, or got it wet?). And #2- everyone I know says it seems like CMS just ignored most of the comments. Not sure on that last one, but hope to do a show on it soon and have some good discussion on it.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Darin Cox of NY got $80k in Mcd payments for his taxi service carting bennies to appointments. Thing is, he didn’t have a taxi license. Robert Rouzaud of Cleveland, OH got charged this week for false Mcd claims for tooth fillings. Mr. Rouzad got paid $343k for fillings for teeth that had previously been pulled, or for patients with dentures. And in one of our rare (rarely detected, anyway) cases of member fraud – Jennifer Garret of Chandler, AZ got indicted this week. Mrs. Garret received more than $70k in Mcd (and other) state benefits, all while her and her husband made loads of cash on their car restoration business. Enough to buy a Nissan 350-Z and Mercedes SUV while toting a Medicaid card in her pocket. Mr. Rouzad, you win! Mr. Cox – perhaps you should consider an Uber career? Mrs. Garret – perhaps Mr. Cox could borrow your Mercedes if he gets out before you do?

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 (remember to water those seedlings!) 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

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