Category: Clay’s Weekly Medicaid Roundup

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

For optimist readers- http://bit.ly/2xIBDi9

LET’S SHAKE IT UP A BIT- And do the fraud follies first this week..

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. Husband and wife duo John and Diane Sink of Cheyenne, Wyoming plead out this week to $6.2M in Medicaid fraud. Their charge? Bogus group counseling bills for sessions that included coloring, karaoke, eating at restaurants and shopping. Nagy Mohamed Abdelhamed of York, PA got popped this week for member fraud (we are seeing more of these- is it more frequent, or just less taboo to talk about?). Mr. Abdelhamed’s case appears egregious – he received $1,124 a month in social security disability bucks and collected $30k worth of Medicaid and SNAP benefits in 2018. Problem is, when he applied for Medicaid (in 2014) he only listed $1k in cash assets, no monthly income and no property. Well- he owned a gas station, a Mercedes Benz E350 and has loads of dough in the bank ($58k at time of writing). Timing? He sold the gas station for $172k in the same month he applied for Medicaid. Richard Quitoni of Middletown, NY was charged with a $200k Medicaid fraud. Mr. Q submitted false claims for cab rides for Medicaid bennies, including some doozies for $50 tolls (they’re not that high anywhere in the Big Apple). Mi Ran Yu of Anchorage, AK was sentenced to 8 months in the slammer this week. Her crime? Stealing $90k using false personal care assistant claims. Aleah Mohammed of Queens used her multi-location pharmacy biz to steal $7.9M by submitting false claims to Medicaid (and Medicare). The bogus scripts were either not dispensed to patients, prescribed as claimed or medically necessary. Sonjay Fonn and fiancée (they’re practicing for husband-wife fraud capers) Deborah Seeger of Cape Girardeau, MO stole $1.6M from Medicaid (and Medicare). This one’s fun- Sonjay did spinal fusion surgeries and ordered all his spinal implants from lovey’s DME company. Problem is, lovey got 50% commission on all sales. Lovey then took the Medicaid bucks and bought her handsome prince a yacht and construction projects. John Bradley of Oklahoma City got 8 weeks in jail for stealing $180k in Medicaid bucks. He submitted a slew of false claims for counseling his niece and nephews. Health Management Associates (the hospital chain, not the consulting firm) will pay $260M to resolve claims it paid kickbacks to docs so they could rip off Medicare and Medicaid by ordering unnecessary tests and increasing admits from the ED.

Mr. and Mrs. Sink, you win this week’s award with a respectable $6.2M Medicaid fraud! Taxpayers, you lose…Total tab in this paragraph is around $278M by my count. Work harder, taxpayers – someone has to pay for all this fraud!

 

OK, NOW SOME QUICK NEWS HITS- For all you fraud junkies, was that like eating dessert first?

MRS VERMA DEFENDS WORK REQUIREMENTS – Seema spoke at a conference in D.C. yesterday and let folks know CMS is maintaining its ground on this, despite all the pearl-clutching.

SHE ALSO LET MCOS KNOW A BIG OLE’ MICROSCOPE IS COMIN’- Clients (and anyone who has been around me the past few years) know I have been saying this is coming since the Mega Reg dropped. An MLR-audit is a natural conclusion of the MLR floor, and it will give CMS a simple way to take back cash.

OREGON CONSIDERING NON-COVERAGE OF NEXT-GEN SEQUENCING TESTS– These are tests used in cancer treatment. Medicare just covered it, but OR Medicaid is studying whether the tests are ready for prime-time just yet. The latest report from the OR Medicaid committee studying effectiveness has a clear non-coverage recommendation. Analysts are watching this one because it could be a model for other state Medicaid programs concerned about the costs of these tests.

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 (marvel at the changing of the seasons) 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: Na auina mai e le Tama le Alo e laveai le lalolagi.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2O1xKhv

For optimist readers- http://bit.ly/2O1y5kh

 

IOWA PER-MEMBER MEDICAID COSTS TRIPLED IN SIX YEARS- Luddite MCO-bashers think it’s the MCOs’ fault. You guys may want to look at the impact of a little thing called taking the “expansion” money as well. The costs of the newly-eligibles surprised the heck out of all of us in every expansion state.

ONE REASON MAINE EXPANSION COULD GO THRU DESPITE LEPAGE’S PROTESTATIONS- It’s a state plan amendment, not a waiver. So the state is basically saying “can we please follow existing law” vs “can you give us permission to get an exception to the law.” Good catch by Michael Shepherd @ Bangor Daily. Roundup readers know all about Mr. LePage. After years of successfully blocking expansion, his agency finally submitted a request to CMS for it- with a catch. LePage sent it along with a memo that said – hey please don’t approve this thing.

SUPER SECRET OHIO PBM REPORT A DUD- Well it ended up being “heavily” redacted, anyway. A judge had considered releasing the report, rich with inside scoop on CVS drug pricing, in all its unredacted glory.

CMS APPROVES 6 NEW FINANCIAL EXPERIMENTS FOR 2019- The Big House approved a new set of APMs (Alternative Payment Models) for next year. MA ACOs, OH episode-based payments, TN retro-episodes, and 2 Washington MCO-based projects.

DEMS TRY TO SUBPOENA CMS DOCS ON WORK REQUIREMENTS– They say it hasn’t been thought-through enough, and inquiring minds in Congressional Lefty Land want to know (do you remember the old National Enquirer tag?). Two of our modern statesmen-luminaries, Elijah Cummings (D-MD) and Raja Krishnamoorthi (D-IL) are leading the subpoena charge. They claim the impact of work requirements on Americans is not being vetted, and they want to see projections, spreadsheets, etc. (keep in mind dear readers, they don’t really care- its all for the cameras. Cummings is set to easily be a part of the “Blue Wave” this November. And while Cummings will probably never lose in ultra-blue MD ((he took 75% of the vote last time)), Mr. K is not as safe and needs to appeal to his Big Healthcare industry buddies, who account for his largest campaign donors by far). Back to the story, though- if we can now subpoena CMS docs for policies impacting Americans that we don’t agree with (apply the “that” either to the policies or the Americans, reader choice), I would love to see the analysis done about 9 years ago on the impact of ACA on Americans. How many Americans with non-Medicaid coverage would lose their coverage? How many Americans would be priced out by absurd deductibles and premiums? How much will the taxes need to go up (i.e. the impact on taxpayers)?

 

CONGRATS AND WELCOME TO KEITH WISDOM- He’ll be the new CEO of Aetna Better Health in KS. Aetna was a recent winner in the MCO awards, and Keith will be the first Aetna KS CEO.

 

OREGON SOS ASKING FOR MONEY TO AUDIT MEDICAID – Sec. of State Richardson wants about $780k to staff up an audit team to figure out just what the heck is going on in the Medicaid program.

 

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- er, not so fast. Not enough time/ space this week, dear, dear fraudsters. Get your fix in the twitter feed. (There’s some big ones in there- I’d say at least $22M in total provider fraud, and a dee-lish $200k member! fraud).

 

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, soon) 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: Otets poslal Syna, chtoby spasti mir.

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

For optimist readers- http://bit.ly/2CUKwu5

4,353 ABLE-BODIED, WORKING AGE ARKANSANS DECIDE FREE HEALTCHARE IS NOT WORTH WORKING (OR VOLUNTEERING) 20 HOURS A WEEK- That’s how many AR Medicaid bennies got kicked off last week for failing to meet work requirements. Assuming pmpm of around $200 (typical for healthy, middle-aged Medicaid bennies), the state just saved $10,447,200 by giving the members a voice in whether the coverage was worth it to them. The flip side is 83-90% (depends on whether you count the denom of those subject in month 1 vs current) of AR bennies met the requirement or were grandfathered in. There are also 1,000 bennies who did not have a job before who chose to go out and get one to keep the coverage. Resistors- Commence name-calling, pearl-clutching, et cet era.

EXPANSION STILL NO DICE IN BAMA- The Good Guvn’r Kay Ivey re-iterated this week that Alabama will not be pursuing expansion any time soon. She seems stuck on this whole “you have to pay for it” silliness. Maybe she hasn’t heard the magical incantations about its free federal money? Or the wise counsel to ignore other tales of woe from expansion states that got shackled to crippling Medicaid debt? Quick, someone call Mrs. Ivey and tell her she simply must take the “free” money.

HEAD OVER 1 STATE EAST, THOUGH- And Stacey Abrams (Dem gubernatorial hopeful in Georgia) is promising Medicaid expansion “is the only answer to Georgia’s challenges.” I must say her background is interesting.. a career in finance and tax law. If anyone can figure out how to get more Medicaid moula, surely it would be a tax attorney. But wait a minute, there’s more- according to an op-ed she wrote for Forbes in the spring, she owes $50,000 in taxes and has outstanding credit card and student loan debt of $170,000. I must say- Mrs. Abrams is uniquely qualified to set Medicaid policy. All she has to do is take her current personal finance skills and scale it up to the level of a state agency. Onward and Upward!

OK, I KEEP READING ABOUT ABRAMS, AND IT JUST GETS BETTER- She is also a romance novelist. I kid you not. Titles include “Hidden Sins,” Secrets and Lies,” The Art of Desire,” and “Deception.” Here is a link to her Harper Collins author page if you don’t believe me. I am unable to resist the temptation to personify Medicaid (as the male interest, a public health Fabio, if you will) in one of her novels. “I looked across the meadow, and the Budget Deficit was staring at me. A look of voracious desire burned a hole into my bones. As he ran to meet me, all I could do was smile and think “Medicaid expansion.” The wind blew through his hair, and we embraced. Mr. Budget Deficit and I were a match made to be. Some might even say, a Federal Match.” FMAP- get it? Ba-dum-bum-bum. Please, please, please Georgia voters- elect this gem. She will give all us writers 4 years of complete silliness to write about.

WE WERE JUST KIDDING ABOUT MORE PRIOR AUTH RULES- Says the NV Medicaid agency. NV Medicaid spending doubled when in expanded, and regulators are desperately looking for any tools to help control costs. They wanted to put more prior auth around certain mental health services to slow down utilization – but providers were loud enough that the state decided not to. Also I think maybe there was a go fund me that raised $10M that said they would NOT call agency officials mean names if they reversed the decision. Or am I getting that confused with some other state?

THINGS IMPROVING IN CT NEMT- We reported previously on the challenged Veyo contract in CT. Looks like there have been significant turnaround efforts (re-training call center reps, improved provider outreach) and the call center wait times are down from 5.5 mins to 2.8. I’m loving the terms and conditions on this contract though- Veyo got $52M in year one of a three-year contract. Lots of terrible press in past few months about service quality, so they have been fined. Total fines Feb. to Sep- $13,500. You can’t make this stuff up.

REMEMBERING 9/11- That’s still ok to do, right? This week we hit the 17^th anniversary of this evil attack on U.S. soil. I remember exactly where I was when it happened (living on a friend’s couch) and most of that day very clearly. Have a 9/11 story? Would love to hear it sometime. Send a note. Give a call. Too young to remember it? Here’s a recording of CNN coverage as it happened.

 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. Haydn Thomas and Catinia Farrington of Raleigh, NC plead guilty to stealing $4M Medicaid bucks using their mental health counseling business to submit false claims. Francis Steen and Alicia Sanders of Savannah, NY got caught in “Operation Find the Dough” (that’s the real name local investigators gave their op, and I love them for it). This dynamic duo provides for us one of our rare member fraud cases (rare in that they got caught and were above our $50k minimum for Roundup appearance, technically). It’s a pretty cool list of thieveries for these two- $23,957 in SNAP benefits, $676 in Low Income Home Energy Assistance Program (LiHeap- bonus points!), and $44,594 in Medicaid benefits. Centers Plan for Health Living in Staten Island agreed to pay $2M to double dog promise it did not steal Medicaid bucks by enrolling non-eligible members and then sending Medicaid the bill. Haydn and Catinia – You win! Taxpayers, you lose – about $6.1M based on the ones we showcased today. Work harder!

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 (get a surprise puppy and forever be a hero in the minds of your children) 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: Tatăl la trimis pe Fiul să salveze lumea.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2wNmryN (1989)

For optimist readers- http://bit.ly/2wLmsDv (1976)

 

POISON PILL IN MAINE- LePage’s administration finally submitted an expansion waiver request this week to CMS. But the Good Guvn’r asked CMS to deny it. LePage sent Veerma a letter, with the gist being – “Hey, a lefty judge forced us to submit this waiver app, but we ain’t got no cash for it. So best to just shoot it down. Wink-wink. Nod-nod.”

SD BALLOT EXPANSION INITIATIVE LOSES KEY BACKER- State Rep David Moore was a proponent of expansion in SD when it included a sunset provision / escape clause if it put SD on a runaway, break-the-bank spending path (like it has in most states that took the “free” money). Now that activists have put full-on, no-way-out expansion on the ballot in November (I-185; not an interstate but rather how they name their resolutions they vote on come election day), Moore has come out against it in a pretty high-profile op-ed. Seems like some other op-ed in the NYT overshadowed this one. I missed the NYT one. Can someone tell me the name of the person that wrote that one?

ASTRAZENECA TO PAY TX $110M TO DOUBLE-DOG PROMISE IT DID NOTHING WRONG- The Lonestar state should have held-out for triple-dog level money. AstraZeneca got caught marketing Seroquel and Crestor off-label. For Seroquel, they worked to get docs to feed it to teenagers, before it was approved for the hip kids. For Crestor they downplayed diabetes risks.

WHY CAN’T COUNTIES IN NY JUST CONTINUE TO PAY BALLOONING MEDICAID COSTS AND SMILE LIKE EVERYBODY ELSE? Well for one reason there’s a new report out reminding county managers how much they must chip in and how big the NY Medicaid behemoth has become. Its now a $70B budget – just for Medicaid; bigger than some state’s entire budgets- and counties have to pay $7.6B of that. And it used to be worse before Pataki and Cuomo put in hard caps on what counties pay.

RELATED TO THAT LAST STORY– NY Medicaid enrollment has grown 57% over the last 10 years. There are now 7M enrollees, which translates into about 36% of all state denizens.

CONGRATULATIONS TO CAROL, BUT MORE SO TO KY– Carol Steckel will take the helm as KY Medicaid Commissioner. She’s one of the absolute best Directors our little world has seen, and I have lost count of how many states she has headed up.  Carol, Congrats! KY team – you made a great choice!

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. John Durmon of Warren, AR was charged with stealing $185k in Medicaid dental bucks. Some good nuggets in this one – he billed for 2,557 x-rays for 85 patients over a 1 year period. That’s 30 x-rays each! Margaret Williams of Anchorage stole an estimated $7M using her nursing homes. Flamingo Eye (that’s the name of the nursing home chain- maybe it made you think of warm places while you were in her crappy nursing home in Alaska?) was used as a rev-max scheme for elderly and disabled members. Waveny Blackman of National Harbor, MD plead to stealing $9M Medicaid bucks using fake patient IDs to bill for bogus medical supply products. Vincent Njong of Silver Spring, MD plead guilty to stealing $66k for bogus billings as a personal care aide (with $66k you just barely made the floor to get included in the RoundUp, Vincent – try harder when you get your billing ID back. Which we all know you will in a few years). Margaret, you win hands down! Taxpayers- you lost $16.3M this week just in these stories that made it the news. You better work hard and smile just thinking how you are helping pay for all this fraud. Somebody’s gotta pay for it.

 

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 (start chopping firewood. I predict a real winter this year) 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: Pitā nē jagata nū bacā’uṇa la’ī putara nū bhēji’ā.

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2LKpRI9

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

 

I WILL BE AT MHPA 2018 IN OCT., WILL YOU? You can check it out here – http://bit.ly/2M4KRhY

If you are going, please let me know. I absolutely love to meet RoundUp readers in real life.

MAYBE LONESTAR STATE PULLING THAT MCO RFP RECENTLY IS MAKING MORE SENSE? TX providers gave legislators an ear full on Wednesday. Many tales of provider woe from meanie MCOs, including delayed payments, more paperwork and tighter utilization control. Providers also complained that there are not enough agency staff, and the program is underfunded. This is an easy fix, guys – more money! Duh, Wilberforce.

MISSOURI PHI BREACH FOR 19,750 CHILDREN- WellCare sent letters reminding kiddos (or their parents) about the need for well child visits- but they sent them to the wrong addresses. Seems to be a recurring problem, with a similar breach involving 1,223 member letters last year.

ADD THE MOUNT RUSHMORE STATE TO LIST OF THOSE ASKING FOR WORK RQUIREMENTS- South Dakotans have spoken (through their duly elected representatives, unless of course Russia swung recent SD elections, too. You never know. I was talking to John Stewart at an Antifa potluck he and I were both at last weekend, and he says the Ruskies swung SD. And I like to get all my political analysis from celebrities. Totes) and they want CMS to allow work requirements for their Medicaid program, too.

 NEBRASKA JUDGE OK’S MEDICAID POLICY BY BALLOT; MEDICAID DIRECTOR ROLE NO LONGER NEEDED- Two state lawmakers had tried to head it off at the pass, but no dice. A judge ruled this week that Medicaid expansion can go to the ballot. Hey voters- which DRG grouper do you think we should use next year? Also, we need to update our CMS-34 reports to pull down the additional funds needed. Do you think we should check box 1 or 2 on section F? Would love your opinion…Cuz y’all are totes awesome Medicaid geniuses.

 TRYING TO DEAL WITH OPIOID CRISES IN OREGON IS TRICKY- New plan to make current chronic pain opioid users taper down to zero over 12 months is not without its detractors. That is a best practice, by the way (at least based on some of the research we are using in our upcoming Understanding the Opioid Crisis online course).

 TN HOSPITAL SUES STATE SAYING IT FAVORS MCOS OVER PROVIDERS- Erlanger Health System in Chattanooga (man that’s a fun word) has sued TN over payment rates to hospitals. Looks like a 2007 law requiring MCOs pay the average in-network rate for Medicaid ED visits may be getting interpreted to be the lowest in-network rate instead. Here’s my question – How do the hospitals that’s suing know any of the rates besides their own? Isn’t that secret-sauce, MCO/provider contract stuff?

FL MCO AWARDS COURT CASE STILL GOING- I thought this was over, but the AIDS Foundation plan that lost out, and the South Florida Community Care Network are still pushing for either a new RFP or new awards (for themselves). You know the old- “do the right thing or favor us. Whichever one comes first, we’re cool with as long as it favors us.”

CA MAY PAY FOR TELEHEALTH FOR SUD TREATMENT- Perhaps seeing IL do a similar thing, CA Good Guvn’r Brown is planning on signing a law that will allow for substance abuse counseling sessions via telemedicine (think a Skype session with your therapist).

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. East Mental Health of Roanoke, VA may get off this time due to prosecutors not meeting a discovery handover deadline in this $45M Medicaid case (there are 3.5M documents to wade through). Christopher East (the owner) is charged with 73 counts of tomfoolery, including making up claims and records needed to nab the Medicaid bucks. Helen Balding and Robin Raveendram – who operated the fairly high-profile Arkansas Preferred Family Healthcare scam – were arrested on Medicaid fraud charges in the past few weeks. Looks like Robin was the brains behind the operation, instructing employees VIA EMAIL to forge $2.3M in claims. Michael Gaines of Baton Rouge (Red Stick for all you parents of curious children) was collared as part of the ginormous federal healthcare fraud sweep recently (along with 20 other defendants in the town). He stole about $2M as a social worker by submitting bogus claims for group therapy for students. Matilda Prince of Mineral Bluff, Georgia was sentenced to 3 years for stealing $1.2M from both Medicare and Medicaid. She billed for optometry/ophthalmology services never provided. Melissa DeLap of Jefferson City, MO was sentenced this week for stealing $106k by falsifying personal nursing claims for 4 Medicaid members. One of the people she supposedly provided care for died in Sep 2016 but was not even reported missing until April 2017. Mr. East, your strategy of “drown em’ in documents” put you over the top and you win this week! Taxpayers, you lost about $51M just in these cases that made it to the news. Keep working hard!

 

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 (plan your winter garden/greens) 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: Pai enviou o filho para salvar o mundo

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2MLMm40

 

For optimist readers- http://bit.ly/2M48HKs

 

CMS SPEAKS ON DEMO WAIVER BUDGET NEUTRALITY- CMS rolled out new guidance this week on how states can prove 1115s are budget-neutral. Looks like there hasn’t been much tracking of this until now (and not even a formal calculation method if I am reading the stories right). Moving forward, these things may actually get evaluated for whether the demonstration waiver “demonstrated” its “innovation.” Good luck to all the DSRIP programs out there. If you are opposed to fiscal responsibility and transparency, I recommend fighting this one with all you’ve got.

  

OKLAHOMA TO PAY FOR DRUGS THAT WORK (AND NOT PAY FOR ONES THAT DON’T)- OK is now greenlighted by the federalis to negotiate prices with drug manufacturers based on whether or not super-expensive drugs actually do anything to help the patient. 1^st contract is with Alkermes for a schizophrenia injectable. Its an interesting approach – price keeps going down as long as the prescription keeps getting refilled (the metric for whether its helping, I guess).

  

HOSPITALS STAND TO LOSE LOTS AND LOTS OF CASH IF KY MEDICAID EXPANSION NIXED; COME UP WITH THEIR OWN PLAN TO FIX IT- Hospital execs in KY have put together a “group” called Balanced Health of KY. It’s big idea? Wait for it… Up the provider-tax magic money scheme to pay for expansion if the whole KY vs Lefties court case doesn’t allow expansion to keep going. For new readers, these schemes allow hospitals to happily pay a “tax” that then gets matched with federal dollars, which then go back to the hospitals. But of course, its mean-spirited to question the ethics of this (like GAO and other investigators have been doing for decades).

  

ADD IL TO LIST OF MEDICAID REIMBURSEMENT FOR MH/BH TELEHEALTH- The Good Guvn’r Rauner just signed a bill allowing Medicaid to pay behavioral health providers for telehealth. Probably easier now that IL got $2B from feds to address the opioid crisis. IL already allowed psychiatrists and FQHCs to get paid for telehealth; the new bill opens up payment for clinical psychologists, social workers, anps and other mental health professionals.

 

“MEDICAID IS THE ONE FOR OLD PEOPLE, RIGHT?”: SENATE WANTS TO HEAR FROM CMS ABOUT FRAUD- Senators (those wise old, Medicaid policy experts making all the big funding decisions) heard from Ms. Veerma on Tuesday. They were particularly interested in her thoughts on fraud in the program, as well as insights into possible recoveries against TX for its uncompensated care financing scheme (prob a magic-money/provider tax scheme but I don’t have the details). Senators also heard from GAO officials the same day. GAO shared insights from its recent reports about CMS not having enough data to perform effective fraud monitoring. Coming out of the hearings, all Senators unanimously agreed to with-hold 10% of federal funds until somebody actually did something about fraud. Just kidding! Everyone agreed that Medicaid fraud is clearly Mr. Trump’s fault and should be included in the scope of Mr. Mueller’s investigation. #Impeach! #Resist! #1984!

 

GRANDMA GOT RUN OVER BY A PRIOR AUTH SYTEM: AFTER COURT BATTLE OVER WHO IS FINAL SAY ON COVERAGE, UNITED HEALTHCARE HAS TO BUY WHEELCHAIR FOR GRANDMA- UHC Iowa repeatedly denied a nursing home resident a request for a special wheelchair after 3 court cases where it took the unusual step of fighting it. Anyone know why? Seems like not worth the PR, but maybe I am missing something…

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph-  Not enough time this week, my dear, dear fraud junkies. Check the twitter feed for a lot of shared cases, though (at least 20 cases).

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 (get up early – the cool morning breezes will remind you of things forgotten) 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: Ojciec posłał Syna, aby zbawił świat

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2M48HKs

For optimist readers- http://bit.ly/2M4seul

(There is somewhat serious talk of a Mostly Medicaid sing-along at the MHPA conference in DC in October. Sign up here and send me a note if you want to join the band – http://bit.ly/2M4KRhY)

 

FIRST A SHOUT OUT TO ALL MY NEW i2i PEEPS- Had an amazing time in PHX (even if it was 147 degrees, Celsius) with the i2i team this week. Got to see all the really cool, market leading things this team does in the Medicaid space. Check out their website here – https://www.i2ipophealth.com/

AND WE’RE OFF! / PINCH ME I’M DREAMING- The NC managed care RFP was released yesterday. After so long expecting it, its hard to believe its finally here. Know who I really feel bad for in all this? The RFP reviewers. Best I know EVERYONE is bidding on this thing…

HOW MUCH IS TOO MUCH? The Ohio Medicaid saga around spread pricing by PBMs is ramping up. Optum joined the CVS lawsuit this week to keep the secret sauce secret. State officials want to release data on how much the PBM is charging beyond price of drugs; CVS and Optum don’t like that none too much. Stay tuned. Will cover on Monday’s news show if you can join.

NEW MANAGED CARE REGS UNDER WAY? In addition to possibly revisiting the MegaRule itself, CMS has started the review process for new MCO regs around provider enrollment. OMB apparently got it on Aug 3.

LONESTAR STATE GETS $110M FROM RX SUIT- AstraZeneca will pay out a truckload of cash (that’s nearly enough to pay off Iran in the middle of the night- oh wait that was $172B….) to Texas to settle allegations it marketed Seroquel and Crestor for off-label indications to docs. They apparently were already in trouble for similar shenanigans when they did this particular bit of Double-Plus UnGood.

 

YOU KNOW THERE’S A LOT OF WORK TO GET READY FOR EXPANSION. NOW IF ONLY CMS WOULD APPROVE IT- Regs have to be updated, systems prepared, sister agencies brought on board. TONS of work (check the twitter feed for an article on the efforts to get ready for expansion in VA). You just don’t think about these things when you view “expansion” as a magic spell cast over the land.

 

ANOTHER STUDY REFUTING THE CLAIM THAT MOST MEDICAID EXPANSION BENNIES WORK ALREADY- A nonpartisan (Lefties can claim that word for their think tanks, so why can’t Righties?) Idaho think tank says bah humbug to the coordinated studies showing work requirements won’t matter based on the dubious claim that most subject to the requirement are already working. When the Foundation for Government Accountability (who the heck really wants that anyway?) looked at Illinois, it found 70% of bennies who could work were not working. FGA also estimates that nationally 6.8M (out of 12.4M expansion bennies, who likely could work) are working already.

 

FL MCO AWARD PROTESTS SETTLING DOWN- A FL judge has ruled that Best Care Assurance has no standing in the protests, because it didn’t weigh in when Molina protested. Gotta play to win, folks.

 

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. Shahrzad Haghayegh-Askarian of Norwell, MA was indicted this week for stealing $200k by billing under another dentist’s name. She’s another 2-time offender, paying out $300k in 2015 for other fraud charges. LaGracia Burnett of Haverford, Delaware was convicted this week of $211,492 in Medicaid fraud. She was a traveling therapist and got paid using false claims for behavioral health services in multiple counties. Thomas J. McLaughlin and Joseph Campione of North Andover, MA have to pay back $612k to Medicaid patients that they charged for Suboxone (so they got paid twice- once by Medicaid and again by the patients). Elena Kurbatzky operated a home care fraud AND she herself was a Medicaid bennie. This may be a first. In addition to the cash she stole from MA, she also hid her $2.3M income so she could herself get Medicaid benefits. You go girl! I think Ms. Haghayegh-Askarian is the clear winner. Her perseverance in continuing to steal even after her 1^st conviction should inspire us all. Taxpayers – make sure to work extra hours this weekend. We have at least $1.5M to make up for with these cases alone.

 

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 (cut down those browning sunflowers if you planted them; or let them dry in place and drop their seeds. According to my hunter friends, this will bring doves.) 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: پدر پسر را فرستاد تا جهان را نجات دهد

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2KqKJn8

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

 

THIS IS NEW- As part of an investigation into a plane crash in AK, Medicaid Director Brodie has had to clarify that Medicaid does not pay for flying groceries and building materials when you happen to be going to a Medicaid visit. Basically the $90M AK NET program uses planes, and a Medicaid bennie en route (with some extra baggage, apparently) was on a plane that crashed recently. She and her 2 year old are ok; the pilot died.

UPDATES ON 2 FL CONTRACT PROTESTS- The AIDS Healthcare Foundation is still ticked about losing its contract in the latest round of FL MCO awards. Protests were planned for Thursday to blame the Good Guvn’r Scott. Scott says the plan is just a private sector business that is mad their revenues were awarded to another plan. Also in FL- Argus Dental and UHC both withdrew their protests of the latest MCO awards. Their protests were related to the new scope of dental services in FL Medicaid, touted as the “broadest dental package ever available to Florida Medicaid recipients.” Congrats to our friends at Liberty Dental, DentaQuest and MCNA Dental who all won in the recent awards!

GOOD NEWS OUT OF OHIO RE OPIOIDS- CareSource announced this week that opioids scripts to its members have decreased 40% in the past year and a half. The MCO is working to reduce it 50% by the end of 2018.

KAISER DROPS RURAL COLORADO MEMBERS TO INCREASE ACO SUCCESS ODDS- About 2,500 members in the northern, southern and mountain areas of CO were dropped by Kaiser Permanente this week. Kaiser will continue getting cap for the 670,000 members in easier-to-serve areas of CO, however.

 NH SCHOOL-BASED SERVICES PROGRAM TOUCH AND GO- NH lawmakers passed a funding bill last year to provide speech therapy and other services in schools to all Medicaid-eligible (not just those enrolled) kids in schools. Recent changes in federal funding rules allowed for an additional bump of $28M to the program. Latest news out of Concord suggests program officials are running behind on implementation work, and school starts in just a few weeks.

 NATIONAL EVV REQUIREMENTS DELAYED-  President Trump signed a law this week that delays the much-anticipated electronic visit verification (EVV) components of the 21^st Century Cures Act. Major requirements to include EVV were set to begin Jan 2019 (new dates are in 2020). Disability advocates have opposed requirements related to GPS tracking of homecare workers and celebrate the delay. Overall, this is a loss for those of us concerned with reducing the egregious fraud in homecare services.

 

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. Salwa Albayati of St. Louis was charged for her role in a personal care services scheme. She and her caregiver billed Medicaid $700 every 2 weeks, including times when Ms. Albayati was in Europe and the Middle East. Salwa took a $420 cut out of every payment. Total bill since 2011 is $241k. Compassionate Homecare operators Carol Anders and Ryan Santiago of Raleigh, NC were ordered to payback the $585k they stole from Medicaid (and another $2.5M in penalties). Pretty much a typical services-not-rendered, not allowed per policy scheme. Wossen Ambaye and Haimid “Mookie” Thompson of Buffalo, NY stole $1.2M using an NET scheme. Lots of billings for trips that never happened or were not in accordance with Medicaid policy. Gena Randolph of SC can make the dead speak, at least according to her Medicaid claims. Randolph was convicted this week for stealing $2M using bogus speech therapy claims (including services for members who were dead). Bonus – She was also convicted of Medicaid fraud in 2012. (Special thanks to Mark for sending this one in). Mustak Vaid of Brooklyn was sentenced to 18 months in the slammer for serving as the face of a 6-clinic fraud scheme operating on Medicaid cash. Vaid and Aleksander Burman ran clinics that stole about $30M from Medicare and NY Medicaid. Features of the scheme include falsifying medical records to get around pesky medical necessity requirements, hiring corrupt doctors to pose as owners of clinics and billings for supplies and services never provided. Ms. Randolph, you win this week’s award! Your perseverance and can-do attitude as evidenced by 2 Medicaid fraud convictions in 6 years put you over the top. Taxpayers, you lost $32M on the schemes uncovered this week.

 

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 some weeding) 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: پلار زوی ته واستول ترڅو نړۍ خوندي کړي

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2K6c8L6

For optimist readers- http://bit.ly/2K1pTKH

MEDICAID ROLLS KEEP DROPPING IN FL- Current estimates show about 500k less bennies on the roll for this SFY compared to last. One theory- once the state started using Equifax to link income data to Medicaid eligibility, a huge amount of bennies who made too much money were dropped.

WORK REQUIREMENTS IN MS? NOT IF ADVOCATES HAVE ANYTHING TO SAY ABOUT IT– The Tupelo protest machine is starting up. Agency officials submitted a plan for adding a Medicaid work requirement, but groups like the Mississippi Health Advocacy Program and Community Catalyst have begun official opposition in recent weeks.

TREASURE STATE SURPLUS MEANS MORE TREASURE BACK TO PROVIDERS- After some initial confusion over whether the agency was following court orders to reinstate nursing home payment rates, The Good Guvn’r Herbert announced full rates for the huge facility-provider lobby (er- I mean nursing homes) were back on. How, you ask? MT apparently has a revenue surplus. The extra cash will be used to undo a 2.99% rate cut to nursing homes and for mental health case management funding. About $45M is getting pumped back into the Medicaid budget.

 THE GRANITE STATE WANTS TO UP PROVIDER PAYMENTS, TOO- Seems the migration of about 50,000 Medicaid members from a private commercial program (exchange-subsidy program maybe)? to Medicaid managed care will cause substance abuse providers to see about a 50% drop in their per diem. Lawmakers met this week find another $7.5M to avoid the drop in provider revenues. New Hampshire currently has a $22M surplus- making the SA providers whole would take about a third of it.

NEVADA SET TO REDUCE ALLOWED NUMBER OF COUNSELING SESSIONS- Medicaid members can currently get 26 visits per year. If a new policy designed to combat fraud by mental health providers goes into effect, the total allowed visit will drop to 3 per year – before the provider has to submit more paperwork to authorize additional visits.

STRONG GROWTH REPORT FOR ANTHEM- Highlights include: 23% YOY revenue growth, with operating revenues now at nearly $23B. A drop of about 880k lives was attributed to shedding exchange plans. Class, remember: you make money on Medicaid (you pretend to assume risk); you lose money on exchanges (you have actual risk). Reports also show an expected increased emphasis for Anthem on Medicare opportunities.

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. Waveny Bleckman of D.C. pled guilty this week to stealing $9.8M in Medicaid bucks using his DME company. Georgia Phillips of Brownsville, TX was ordered to pay $500k back to Medicaid after stealing taxpayer dollars (Medicaid funds) using her speech pathology clinic. Slow week for Medicaid fraud (I’m sure that these 2 cases were all the fraud that happened, so no worries taxpayers!). Waveny, you win hands down!

DON’T FORGET TO BOOK YOUR OCTOBER TRIP FOR MHPA- I will be there again this year. Should have discount code for MM readers soon. Check out agenda here – http://www.medicaidconference.com/conference/program-tracks

 

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 unusually cool weather) 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: Atate anatumiza Mwana kuti apulumutse dziko lapansi

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2LyE8IO

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

GIVE A WARM WELCOME TO THE NEW IL MEDICAID DIRECTOR- Patti Bellock took the helm 7/11. Welcome!

LET’S TAKE ANOTHER LOOK AT THIS KY THING- Undeterred by the litigious slowdown from a few weeks ago, KY officials are revising and resubmitting their work requirements waiver to CMS. Keep in mind the judge did not rule work requirements to be the problem- but that CMS did not do a proper review of the impact. CMS has announced a 30-day comment period on the waiver. If you need boilerplate on how the sky will fall and the world will end if the waiver is approved, I can send you a few links to think tanks who are actively coordinating propaganda – er, I mean comments / responses “curated” to make sure the “public” opinion is heard correctly. I am sure it will be balanced.

 

LAST FRONTIER STATE ASKS FOR $15M BACK FOR OOPSIE PAYMENTS- Seems like the AK legislature passed a 10% cut to Medicaid (that’s called a law when its passed by the legislature), but the agency forgot to make it happen. This has been going on since October, so now the agency has paid out $15M illegally (that’s what its called when you do something in violation of a law) to providers. Now its sending out pretty-please-send-the-money-back letters to providers. More than a few providers are saying they’ve already spent it and can’t afford to pay it back. Somebody call Bernie. I know he’s been working on College-For-All and Healthcare-For-All. Surely he’s solved it by now.

DESPITE CLAIMS BY ADVOCATES THAT MOST MEDICAID BENNIES WHO COULD BE WORKING ALREADY ARE- A new report in Illinois shows that 70% of able-bodied Medicaid expansion bennies are not working.

EARLY NUMBERS IN ON BENNIES FAILING TO MEET WORK REQUIREMENTS IN THE NATURAL STATE- A little north of 7,000 members did not report enough hours in June to be compliant with the new rules in Arkansas (there are another 18,000 subject to work requirements but who don’t have to report hours due to other exemptions). About 450 members did meet the requirements. Those who missed the mark in June could lose coverage if they go 2 more months without working.

 

THE MOTHER OF PRESIDENTS STATE PAYS MOTHER OF ALL RX MARKUP FEES- An early look at the report looking into how much Medicaid money CVS Caremark (the pharmacy benefits manager, or PBM) kept in Ohio shows about $224M staying with the middleman (CVS) after pharmacies were paid. Not sure if that’s a big deal or not? According to the report the OH CVS markup is 3x what CVS normally gets in other markets. This kind of reminds me of 340B providers not passing on savings to poor patients, but that’s another kettle of fish…

ADD IDAHO TO THE LIST OF STATES WHERE VOTERS ARE ALL NOW MEDICAID DIRECTORS- Expansioners have certified the number of signature required to get expansion on the ballot in November.

ANOTHER TROUBLED NEMT MARKET IN THE NEWS- We covered challenges with Southeastrans service in Indiana on the show this week. Looks like Veyo continues to struggle in Connecticut. Recent reports include high profile meetings with healthcare providers and advocates who are voicing complaints over missed rides. In their defense, Veyo delivered 364,000 trips in May and only 478 complaints were filed (less than ½ of 1 percent of rides). Some of the complaints get into how long providers have to be on the phone to resolve issues, and whether drivers are showing up with appropriate vehicles (i.e. wheelchair accessible).

 

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 was a huge, national Medicare/Medicaid fraud dragnet in late June and most of the stories out now are from that. I will hit the highlights from that sweep: Health Quest Systems of NY will pay $14.7M to double-dog promise they are not guilty of upcoding E&M visits paid for Medicare/Medicaid. Brent Clarke of PA will pay $360k for his role in a medically unnecessary services scam. Mayura Kanekar of Queens and 12 of their (not sure if that’s a male or female name) closest criminal buddies were charged with stealing $163M from Medicare and Medicaid this week. Looks like this scam involved 5 physicians, 3 therapists and 2 pharmacy owners (there’s a high school algebra word problem in there somewhere). “Dr” Abraham Demoz of Oceanside, NY was nabbed (along with 4 of his buds) for his role in stealing $163M in an illegal kickback scheme using referrals to their clinics. Once they got the patients to their clinics, they then billed for lots of physical and occupational therapy. That’s it for the ones from the big national sweep. The biggest one that I think was Caid’ only this week was in MA. Michael Davini of Worchester, MA will go to court over fraud charges related to a $19M scam in which he is accused of money laundering and false bills to MA Medicaid for non-emergency transport. The case says Davini billed for wheelchair van rides for members not in wheelchairs. Mr. Davini – you win (we keep the award Medicaid-specific)! Taxpayers – you lost at least $350M this week by my count.

 

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 (have a water balloon fight, or run in the sprinkler) 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: Faderen sendte Sønnen for å redde verden