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

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).

 

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