Category: Clay’s Weekly Medicaid Roundup

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

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

Don’t forget Monday’s Monthly Medicaid News Roundtable show where will cover a lot of these in more depth with the panel. Sign up for free here –

http://www.mostlymedicaid.com/?page_id=3176

 

 Bigger than normal fraud section at end today. Enjoy!

BLUEGRASS STATE MEDICAID REFORM SLOWED DOWN AT THE BENCH- Most of you saw that the KY work requirements plan was stopped by a judge’s gavel last week (an image of king dropping his scepter to note a ruling flashes in my mind). Thank you to all the readers who sent in various analyses and insights. It appears to be a KY-only ruling, in that the judge found CMS did not consider whether this particular request facilitates the “purposes and goals of the Medicaid program.” I invite all readers to read Title XIX of the Social Security Act (which defines Medicaid) and weigh in on what the purposes of the program are. Here’s a link to the full act- https://www.ssa.gov/OP_Home/ssact/title19/1900.htm

My hot take is that SSA defines Medicaid’s “purpose” as a way to give states cash for health care (for the states that want to pay their part of it). Not the lofty insure the uninsured, etc stuff we have come to ensconce in Medicaid mantras some 50 years later. Do I think the judge actually read SSA to compare the request to the “purposes and goals” of Medicaid? Doubt it.

DID YOU KNOW UNIONS GET A CUT OF MEDICAID HOME HEALTH DOLLARS? I DIDN’T – Talk about graft. Seems Dear Leader O gave unions a tidy little bundle of cash under ACA. Here’s how the scheme works: ACA included a rule that allowed states to divert a portion of home health care workers to mandatory union dues. Usually federal regs don’t let Medicaid provider payments go to anyone but the provider, but O made an exception. How much did unions get from this tiny little vig off the ACA pie, you ask? About $200M each year. Plenty to send back in through campaign contributions, etc. Quick lefties – claim the moral high ground somehow. Tell me how this is anything but slimy politics with “healthcare for the poor” as cover.

NEW TELEHEALTH REPORT OUT- Well 2 reports actually (check the site for links / copies in the next few days). Similar results as last year’s info, I think. Telehealth is now defined in most states, Medicaid has better payment than commercial, still struggling to get services that happen while patient is sitting in their living room covered (besides remote patient monitoring- have to go to a provider office that is part of a hub/spoke model for most consults).

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. Rebecca Norris of Frostburg, MD (sounds chilly) plead guilty to nabbing $850k using her Appalachian Wellness Centers to do video-based therapy but billing it as face-to-face. Chin Kim of Bethel, AK has been charged with stealing Medicaid dollars by taking vouchers bennies are given by the state to cover travel costs (flying in to Bethel to get care, hotels, etc) and then submitting them to Medicaid for payment. That part seems ok per rules- it’s the $4k to $57k increase in one month that put Kim on the MFCU radar for fraudulent billings. Dana Trandahl of Butte, MT is charged with billing $74k in services not provided using her counseling service. Galit Levi of Queens plead guilty to stealing $67k in Medicaid benefits by hiding her annual income of $225k. In a very unusual twist, she paid it all back and got a $1,000 fine. Hope In-Home Care of Newport News, VA has agreed to settle Medicaid fraud allegations by coughing up $3.3M (to emphasize their innocence, of course). Charges included false claims for personal care services, falsifying statements of eligibility for members and for prior authorization and billing for services not provided. James Burkhart of Indianapolis was sentenced this week for his role in the American Senior Communities scheme which stole $10M from Indiana Medicaid using an elaborate vendor kickback model. The scheme facilitated multiple frauds by allowing vendors to send higher bills for their services to nursing homes, which would in turn be reimbursed by Medicaid (basically gaming the cost report if I understand correctly). Mom and daughter duo Julie Longton and Leanda Zupka of Norwich, CT will pay $300k back to Medicaid that they stole using unlicensed therapists in their counseling business. Galit – you win! You paid it all back, which never happens. Taxpayers, you lose. Which happens every week (but you better smile and take it, else you’re a big ole’ meanie!).

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (cut the grass-but bag it if you have weed problems. No need to put the seeds right back on your lawn) 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: Bubālē chōrālā’ī sansāralā’ī bacā’unubhayō.

Soundtrack for today’s RoundUp pessimist readers-

http://bit.ly/2MySpFq

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

SIMPLIFY THE MATH, UP THE SAVINGS- Pretty entertaining to watch the debate over “savings” of the new Medicaid managed care ramp up in Iowa (I say new, its been a year or 2 now, just seems new since the media keeps tarring and feathering it anew each day). The numbers have been a roller coaster, hitting a high of $232M last year, then dropping to $47M. Now the “savings” is back up to $141M. The New New Medicaid Math is simpler and better, mainly because it shows more savings. Here’s an idea – how about fee for service sucks in terms of quality of care and that’s a good enouch reason to have managed care in Medicaid? Is that good enough to let Iowa move into the 21^st century healthcare system for Medicaid members? Let me know when we start scrutinizing savings estimates of more popular “innovations” like social determinants waivers or health lifestyle / member engagement programs. Ready to have your savings math beaten up every day for 2 years on those?

 

CMS SAYS NAH (READ THAT IN YOUR BEST APPROXIMATION OF BOSTON ACCENT) TO MA- Short backstory, Massachusetts wanted to opt out of the Medicaid Drug Rebate Program because it forces them to pay for whatever drugs are approved on the federal formulary (I’m simplifying). Early analysis suggests MA was hoping to have their cake and eat it, too. They wanted to exclude some drugs in their program, but also keep getting the rebate goodness on other drugs via MDRP. CMS said that is not workable. Sort of the basic way the MDRP functions, folks. Maybe MA will revise the request to opt out of MDRP altogether? Or follow OK, which recently got its plan approved to modify its Medicaid rx program (by adding more rebate deals tied to outcomes of the drugs)?

 

CMS READY TO START CHECKING RATE CELLS- CMS will be doing some verifying of who goes in what rate cell. For non-MCO readers, think of rate-cells as buckets that members get put into. The MCO gets paid different amounts based on the bucket. If Clay is in the 20-25 year old healthy male bucket, the MCO might get $200pmpm. If instead he is in the TANF-SNAP-SSI-DISABLED-ELDERLY bucket, the rate cell would pay out much higher (maybe around $1,200 pmpm depending on the market). From a state perspective, you want to get as many people as possible in the ObamaCare Magic Money bucket / rate cell – because that’s the one feds pay almost all the costs for (going rate of 90% as we come down from the high of ACA expansion coercive fmaps). CMS will now be doing more audits to confirm that enrollees are correctly placed in the pre- or post-expansion rate cells. The agency also announced audits of states like CA that OIG found to be incorrectly enrolling people in Medicaid.

 

HOLY SMOKES BATMAN! UPDATE THE WORK REQUIREMENTS MAP TO SHOW MICHIGAN- I think this is the state that the legislators passed a law that would stop salaries for the Governor’s HHS staff if he didn’t submit a waiver request to CMS for work requirements. Looks like the strong-arm tactics worked (I have never seen anything like this in all my 87 years of doing Medicaid). The bill passed includes terminating the expansion program (people who did not have Medicaid before 2014 or so) if CMS does not allow the state to charge a 5% premium to able-bodied, non-elderly bennies at 100-133% federal poverty level. The gloves are off.

 

CONGRATS TO THE KANSAS MCO CONTRACT WINNERS- Aetna, United and Centene (Sunflower State Health Plan) all won renewals in KS this week. Amerigroup got the boot. Winners – Congrats!

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award.  Susan Britt of Norwich, CT was arrested this week on charges of getting paid $91k for services not provided (she’s a mental health counselor). Felicia Blount and Charlotte Hunter of Gary, IN were charged with stealing $100k using inflated mileage reports in their medical transportation business. Collins Anyanwu-Mueller of Westchester, NY was sentenced on Monday for stealing $392k from Medicaid using false claims for private-duty nursing care. He got caught when investigators found claims for the same time he was in Europe and for other times when the members were in a hospital or being cared for by another nurse. Frank Patino of Livonia, MI got nabbed for stealing 112M Medicaid bucks using an illegal opioid prescribing scheme. There is something in this story about Patino giving away free hams, but I can’t verify it. Please, please, please write in if you know anything about the hams. Patricia Lancaster of Wheeling, WV was convicted on false claims charges this week. She stole $181k from Medicaid by submitting false claims for “adult companion services” (seems like personal care services, based on what I am seeing). Problem is (in addition to the bogus claims) that she lived with the patient – which made her ineligible for the payments. She knew this, which is why she tried to hide it from the agency. Mr Patino – the $112M and intrigue of the hams put you over the top this week. You win! Taxpayer you lost (about $113M to be exact, just on the ones I found 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 (batten the hatches! Summer storms are here) 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: Etseg delkhiig avrakhyn tuld Khüügee ilgeev

 

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Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2Ib98vV

For optimist readers- http://bit.ly/2Mdn62N

 WELL YOU SAID IF THE LEGISLATURE FUNDED IT… If you’ve been following LePage vs Expansioners, you know that the Good Guvn’r of Maine has sworn to not submit an expansion request to the federalis unless the legislature came up with the money to pay for it (seems logical, but I know desire/emotion trumps logic in our world…). On Wednesday a judge upheld LaPage’s right to not be forced to submit an expansion plan against his will. Then (also on Wednesday) the ME Senate and House approved $60M to expand the state’s program. Your move, Mr. Governor.

 NEW REPEAL / REPLACE EFFORT VIA APPROPRIATIONS? The House GOP budget teed-up on Tuesday includes $1.5T in cuts to Medicaid and “other healthcare programs.” There may also be hooks in the bill to allow for repealing ObamaCare without the Dem votes normally needed (I think this is the “reconciliation” maneuvering but not sure yet). GOP leaders are sounding the alarm over mounting debt and related fiscal crises if we don’t reduce spending. Where are my Medicaid #Resistance Fighters? Shouldn’t you be freaking out / yelling right now? By the way, the new legislation is called “A Brighter American Future.”

 

MEDICAID FRAUD UP 157% SINCE 2013 AND SENATE LEADERS SHOW CONCERN- A new report from the Senate Homeland Security and Governmental Affairs Committee shows Medicaid fraud skyrocketing since 2013 (and it was already ridiculously high). The report claims $36B is lost to Medicaid fraud each year. Some members are laying the blame at CMS’s feet for not “taking basic steps to fight Medicaid fraud.” It doesn’t help CMS’s case that GAO has been sounding the alarm for years. Of the 11 anti-fraud recommendations GAO has made in the last 3 years, guess how many CMS has implemented. Zero. I have been tracking and trying to bring emphasis on the disgrace that is Medicaid fraud for 15 years now.. Not getting my hopes up this report will change much.

 

DEMOCRATS OPPOSE FUNDING NEW OPIOID TREATMENTS VIA MEDICAID- The House passed a bill on Wednesday to cover new treatments for opioid addiction in Medicaid programs. The legislation will allow for funding for addiction treatment to go to facilities with more than 16 beds (this

gets at the IMD exclusion for those familiar with this part of the space). States have been asking – and receiving- waivers to allow exactly this funding. But proponents say the waiver process is taking too long and this law would speed up access to treatment. Opposing dems said it didn’t go far enough.

HOW MUCH DID YOU PAY IN STATE TAXES LAST YEAR? 17% OF THAT WAS FOR MEDICAID – Up from 13% in 2000, according to a new Pew study. All 50 states spent a higher percentage of their funds on Medicaid in 2016 compared to 2000. LA had the highest surge, going from 11% in 2000 to 24% in 2016 (they also expanded Medicaid in 2016).

 

PA AMBULANCES GET 33% MEDICAID PAY RAISE- Standard rates for Advanced Life Support went from $200/trip to $300 in the Keystone State. The Ambulance Lobby (usually its one dude in the state with most of the marketshare) is a real thing. I have seen it in multiple markets over the years.

 

MAJOR CHANGES FOR MDRP? MACPAC (the Medicaid and CHIP Payment and Access Commission) is recommending 2 changes: 1) stop letting pharma set Avg Manufacturer Price using brand and generics, and instead use the prices actually available to wholesalers. This matters because rebates set off of generic prices are lower (and using the generics in the calculation dilutes the amount states can get back). And #2) MACPAC wants HHS to be able to punish manufacturers that don’t provide good enough data to monitor compliance.

MOLINA GETS FLORIDA LOSS OVERTURNED- The MCO had lost its business in 2 regions as part of the recent procurement cycle. After a successful protest, Molina will now continue to serve members in 2 of the 11 FL regions. The new decision is important for Molina – at $550M / year in revenue, the 5-year contract now secures $55M in profits (assuming a 2% profit rate).

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 space this week. Get your fraud fix in the twitter feed (I put 20 or so fraud news items in there 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 (pick tomatoes!) 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: Pityānē putrālā jagācyā tāraṇāsāṭhī pāṭhavilē

 Consulting Services | Free Webinars | Training 

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2HND9BG (from the Arsenio Hall Show – How awesome is that?!?!)

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

 

NY BLEW $1.3B ON IMPROPER MEDICAID PAYMENTS- BUT WHO’S COUNTING?- NY State Comptroller DiNapoli (am I the only one who has long-thought “comptroller” is a very strange word?) released data this week showing $1.3B in “unnecessary” Medicaid spending since 2012. The audit pins the errors on electronic systems. State HHS officials say they are working on the issue and are trying to get the cash back. From what I can tell this could be a mix of inappropriate capitation to MCOs and TPL issues. If anyone in NY knows, please write in.

 

MR BEVIN GOES TO WASHINGTON (OR RATHER WASHINGTON LEFTIES GO TO COURT AND TRY TO DRAG MR BEVIN WITH THEM)- The lawsuit against KY’s work requirements (remember they call it “community engagement”; their opponents call it “work requirements”) is set to have its day in court this Friday. Keep in mind the long list of exemptions means no elderly or disabled person will have to meet the requirements (nor children or pregnant moms)- basically this new Medicaid innovation feature (its done under an 1115 demo waiver) will only affect a subset of the KY Medicaid expansion population. Stay tuned.

 

 NC SAYS NO TO STUDYING EXPANSION- A last minute amendment was added to a rural health bill on the floor this week, but it was promptly removed by the program evaluation committee. Committee leadership says it should be in charge of what gets evaluated, and that all efforts are focused on current efforts around bringing managed care to the state right now.

NASBO SAYS MEDICAID SPENDING TO SLOW DOWN IN NEXT FY, BUT THEN SPEED BACK UP- A NASBO report published this week shows most Medicaid program spending increasing by about 4.5% in FY 18’. When they take out their crystal balls for FY 2019, its around 1.5%. After this slow down, Medicaid hits the gas again and starts spending 5.5% more in future years. The report examines proposed Governor’s budgets each year. If the Medicaid spending adds proposed in those budgets goes through, and additional $5.3B in state funds will be added to the Medicaid industry next year. Well, a lot more than that when accounting for agencies overspending their budgets (which invariably will happen).

 NH SA PROVIDERS NEED MORE MONEY- They currently get $162.60 per patient per day for inpatient substance abuse treatment ($4,878/month). Providers say this is well below cost, and are asking for $10M per year from Medicaid.

 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.  Duke Ellington Ellis of Durham, NC will have to repay $1M (yeah, right!) for his role in fraud scheme in which he forged signatures of licensed psychologists to submit fraudulent claims. His company – gotta love the names they give these things – “Nature’s Reflections” stole $8.7M over the course of the scheme. LaGracia Burnett of Philadelphia plead guilty this week to stealing $211k for false claims for behavioral health services for autistic children. Seems she had broken the laws of physics and was delivering services at 3 different clinics at the same time. Arkady Goldin of Brooklyn stole $1.5M using a kickback scheme involving his pharmacy. He paid a local medical center employee to send expensive cancer scripts his way. Goldin also billed for drugs never delivered. And this is cool- the state figured that out by checking his Medicaid reimbursements against his orders from wholesalers. Mr. Ellis – you win this week’s award on sheer volume alone. Congratulations!

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (build a nice fence) 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: ua tono mai te Metua i te Tamaiti ia faaora i te ao nei

 

Healthplan Consulting Services | Behavioral Health Solutions | Online Training

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2KSCG2Y

For optimist readers- http://bit.ly/2KT2aNX (A Dick Cavett reference for my friend Jeff, the Tall Irishman)

 

 ABOUT LAST WEEK- There was way too much parenthetical thought (I apologize). [I will try to do better this week]. I promise.

 MINNESOTA ASKS FOR WAIVER TO ALLOW RESIDENTIAL SA TREATMENT- Now that views on residential treatment in places with more than 16 beds are changing (under the weight of the opioid epidemic), states are looking to relax rules meant to defund those horror-story mental health facilities from back in the day. If approved, MN will join 11 other states who have recently received the exemption to allow drug addiction treatment in facilities with more than 16 beds.

 NC ADDS WORK REQUIREMENTS TO MUCH-WATCHED WAIVER REQUEST- Journalists now see this as a poison pill to the NC effort based on 1 comment Verma made a few weeks ago about concerns over non-expansion states and work requirements.

GEM STATE REACHES VOTER CRITICAL MASS- The evolving nature of U.S. Government- in which the Constitution is but a piece of junk mail sent to us from those crusty, silly, old (add in still-socially acceptable slur here) guys back in the day from some place in the Northeast I think- now includes voters taking over the power of appropriations from Congress. Seems voters in Idaho are joining the mob of MoveOn-ers who think they can ballot anything they want into existence. Idaho activists confirmed they reached the necessary 58,000 signatures to put Medicaid expansion on the ballot in November. If they had to pay for what they are voting for, they would swipe their card for $3,206 (each, annually) to cover the costs (state and federal) for the 62,000 members their vote will add to the Medicaid rolls. But we all know its silly to expect voters to consider costs of their decisions. That’s someone else’s problem, right?

LEPAGE MAY GET OVERRULED- A Maine judge is deciding whether to order the state DHS to file a waiver request for expansion as chosen by voters. Roundup readers will remember that the Good Guvn’r LePage said he ain’t doing nothin’ to move it forward unless the legislature funds it.

SD WORK REQUIREMENTS PLAN GIVES SECOND CHANCES- SD policy makers have added another step before getting booted off if you don’t meet work requirements. Under the new proposal, bennies would get on a corrective action plan after not working 80 hours in a given month. Then if the CAP doesn’t fix it, they would get booted. The new feature is designed to avoid getting shot down by CMS as “too harsh” in a non-expansion state.

EVERGREEN STATE ANNOUNCES MCO WINNERS- The latest round of MCO awards in Washington concluded this week. Congrats to Amerigroup, Molina, UHC, CHPW and Coordinated Care. Special congrats to Molina and Amerigroup who nabbed statewide contracts for integrated care in all 9 regions.

VA LETS EVERYBODY DOWN-  Everybody hoping for expansion this week, anyway. Virginia Dems were expected to push through an expansion vote on Tuesday, but needed 1 Republican to defect to the SpendMore side. Without getting to much into the weeds of VA legislative procedure, basically this bill needs to get out of committee and it didn’t do that just yet. The majority leader in the VA senate announced this week that he expects it to pass, even if it does take a minute to work out the details. Be patient my dear Dems – you will be able to implode the VA state budget soon enough.

IOWA ON THE REBOUND WITH CENTENE – After a nasty breakup with Amerihealth, Iowa announced Centene is its new love interest this week. Announced this week, will start July 2019. Congratulations to all our Centene colleagues!

 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. Khurram Gondal of Ticonderoga, NY (and 11 other co-conspirators) were arrested this week for defrauding Medicaid out of at least $8M using their bogus transportation business. This scheme includes trips that never happened and kickbacks to complicit bennies. Roshanak Khadem (and 4 others) of Los Angeles were arrested on Tuesday for their part in a $20M scheme. Khadem (aided by a former Anthem investigator, who knew the ropes) and team would bill MCOs for things not provided using the billing numbers from bennies who were happy to get “discounts” on cosmetic procedures. Seems an allergy-related lab test CPT code was a hole about the size of a Mac truck in the MCO edits system. Keisha Demas of Brooklyn was arraigned this week for stealing about $500k, of which $60k was from NY Medicaid via a false claims scam related to her role as a nurse at Interfaith Medical Center.  Congrats, Roshanak- using a former MCO investigator as a fraud consultant gives you the style points needed to win 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 (take some cutting, and propagate something already doing well on your property) 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: il-Missier bagħat lill-Iben biex isalva d-dinja.

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

For optimist readers- http://bit.ly/2y9t7L7

 

HEADED TO BALMORE. DO DROP BY AND SAY HELLO- I will be at MMCC 2018 starting Monday. Chairing a panel Tues morning. Would love for any and all readers at the event to say hi.

 

Y’ALL SIMMER DOWN NOW- NM recently awarded new MCO contracts. So the protests were filed by the losers. And HHS rejected the protests via the administrative process yesterday, so now the losers can take it to court. Yay! Even longer time to make changes needed for the program… Member impacts include uncertainty over whether they will have to switch providers Jan 2019. You have to understand the losers’ position though. It’s a lot of cash. Example – Molina had $1.3B in premium revenue in NM Medicaid last year. Assuming a 2% profit yields $26M a year lost if the protests don’t work out. So as long as the litigation costs less than $75M or so (3 years of premium profit in the market), why not roll the dice and sue? And that doesn’t even take into account impacts on market capitalization on news of losing key contracts, etc. Want to track the impact of lawsuit on stock price? Follow ticker symbol MOH on the NYSE.

  

SOUTH CAROLINA EXPANSION LOBBY PRIMES THE PUMP- The Urban Institute (are they still around?) just released a study showing the amazingly 1-sided impacts of a potential Medicaid expansion in SC. 194k would get “coverage” (please define “coverage” class, and then compare and contrast it to “access,” then triangulate it with “intersectionality” – oh bother, I lost myself) if the state moved forward with expansion. Per the study, the state would “only need to chip in $111M per year.” Because you know its magic federal money, that comes from the sky every time you wish upon a star. It makes no difference who you are. Anything your heart desires will come to you (and other states will pay for it!).

 

ALASKA SLOWING HOSPITAL PAYMENTS- Since the legislature did its job and passed a budget (you know, how the US Constitution and all state ones work?), there is $20M less than requested (do not make the mistake of confusing requested with “needed”) going to Medicaid between now and June 30. That’s about 45 days, people. So when you realize how people are freaking out (that they have to follow what the legislature says when it comes to appropriations) its clear Medicaid is living check to check. Normally the state cuts the checks weekly, but starting this week they will float larger providers a bit longer. Some reps point out that all this is driven by higher than projected costs of Medicaid expansion (remember when the Good Guvnr Bill Walker did it all by his lonesome back in 2015?), but those reps are quickly silenced and reminded on the non-politic nature of such comments. Even more daring reps point out that services for the most vulnerable are being impacted because of expansion overloads. Those reps are so offensive that they are immediately sent to Siberia. You can see it from the Governor’s back yard, you know.

 

PATIENTS SUE ILLINOIS OVER MEDICAID DELAYS- Illinois just can’t get it together. Seems like the state thinks after it sent us the best-President-ever they don’t have to do anything else at all. Resting on their laurels. Latest chapter in the dumpster-fire story (tragi-comedy? Especially considering sub-plot arcs over the years like Blagojevich) of the Prairie State is a lawsuit from patients suing over long-delayed eligibility applications. Seems the state is out of compliance with federal rules on determining temporary eligibility for new applicants. They are supposed to process apps within 45 days. The biggest pain points are in nursing homes. Per the write-ups I’ve seen, there has not been a single applicant approved under temporary eligibility since the summer of 2016.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph – not so fast. I was too wordy up top this week. Plus gotta keep you coming back for more.

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 (time to get the yard in shape for your Memorial Day party) 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: lēākaṁ rakṣikkānāṇ pitāv putrane ayaccat

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

For optimist readers- http://bit.ly/2jNiSm7

 

QUICK ANNOUNCEMENT – Our webinar provider had a “major outage” yesterday and we did not get to do the full MESC 2018 preview webinar. Look for details re a rescheduled show in the newsletter.

BEEHIVE STATE TILTS AT WINDMILLS – Please write in if you get the reference (no googling!- but you can go to your local library and check the 863s under Cer)… Officials in Utah continued the farce of a post-obama expansion this week by trotting out a series of public hearings to discuss adding 90,000 adults to the rolls. Do people really think CMS will approve this? Or maybe I missed something and Utah is willing to pay 50% of the costs (vs the sweet, sweet 90-100% deal offered in years past?). Think they will agree when CMS comes back with work requirements and other “evil” conditions of paying for it?

 

IT’S GETTIN’ HOT IN HERE; I’M GONNA CUT SOME BUH-JETS – Apologies to Nelly fans worldwide. Louisiana may be doing it for reals, though. Letters were sent to 37k bennies that they may get booted from Caid based on recent changes to Medicaid budgets. The proposed budget would remove 4 programs (not sure which ones, please write in if you know more). Bennies will also get contacted about getting services on other programs they may still be eligible for.

NO DICE, KANSAS! CMS rejected the KS waiver request to establish a 3-year limit on Medicaid benefits for non-disabled adults. This doesn’t bode well for AZ, UT, ME and WI who have asked for a similar budget relief measure. Since this rejection is in keeping with the dominant paradigm of The Healthcare Left, many are confused. At time of running this article, CNN was trying to figure out how to tie this to Stormy Daniels. Or the Russians. #Resist!

ILLINOIS GETS A LOT OF CASH TO HELP FIGHT THE OPIOID CRISIS- CMS approved a $2B transaction to IL this week, as part of an 1115 waiver application to address challenges in meeting the needs of behavioral health patients. Per analysis used to make the case for the funding, bennies with behavioral health needs drive more than half of all Medicaid spending. July 1 will see new efforts funded around short-term drug addiction treatment centers, moms and babies showing drug withdrawal symptoms, employment assistance and other programs. IL had asked for some of the cash to go to things related to social determinants of health (like rent payments), but CMS shot that down.

TRIBES CONCERNED OVER NEW MEDICAID RULES APPLYING TO THEM- Seems some policy statements / positions in April from CMS / Trump classify tribes as a race. The next step in the Administration’s argument is that exempting tribes from work requirements would show preference for one racial group over another and thus be discriminatory. Different tribes are assessing the impact on them, with Cherokee Nation putting about $46M impact due to a proposed work requirement in OK.

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. Beverly Coker of Windsor, CT was sentenced for her part in a $214k fraud that involved unlicensed providers. (She got probation while her co-conspirators got much harder sentences. May be because she is 70 years old). New Era Rehabilitation Center in Bridgeport, CT will pay back $1.37M for double-billing for methodone treatment. There are some services-not-delivered details in that one, too (check the twitter feed for more). Mrs. Coker – You win this week’s award because you are the oldest convict ever to appear in the Roundup! Congratulations!

 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 (Meet a new neighbor this weekend) 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: Bapa menghantar Anak untuk menyelamatkan dunia

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2HSgc0S

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

 

LET’S JUST PRETEND THERE IS AN ENDLESS SUPPLY OF MONEY FOR MEDICAID AND EDUCATION. YOU KNOW, IT’S FOR THE KIDS- A new study finds that investments in public education (higher ed in particular) are the only budget item decreasing in recent years (since 1987 if you want to get precise. Please help me continue the fantasy that 1987 was not 31 years ago). It also finds that Medicaid is the single biggest reason less money is being spent on your local college. Here’s a link to the study- http://bit.ly/2HRqGxP

 

LOTS OF UPDATES ON STATE FLEXIBILITY REQUESTS TO CMS- The next several items are part of a larger trend in activity on the state flexibility requests front.

 

VERMA TOYS WITH NEW SUBSIDY? There’s a new donut hole in town. The one between Medicaid and exchange ineligibility. Recent comments from CMS head Seema Verma have some analysts looking for a new subsidy that would help pay costs for those who make too much for Medicaid but also too much to get an exchange subsidy. Keep an eye on this one, but don’t spend too much time on it. I don’t see newer tax-payer funded payments for able-bodied adults in keeping with the current Verma Vibe.

 

MICHIGAN WORK REQUIREMENTS BILL DEBATED THIS WEEK- Supporters point to 100k unfilled jobs in Michigan, and the 47k Medicaid members who would be required to find work.

 

OHIO MOVES FORWARD WITH WAIVER APP TO CMS- We now have a new one in the hopper as of Monday. Kasich was reportedly found sobbing in a closet in Toledo when he heard the news. This one has pretty normal exemptions – no one over 55, no one seeking substance abuse treatment, and no one with serious physical or mental health issues. About 5% of expansion enrollees (you know that group that never had Medicaid until the magic wand of Obama fixed healthcare for everyone by ballooning Medicaid to ginormous sizes) will be subject to the requirements. From what I have read, you and I also have to go to work on Monday. #Resist!

 

LOUISIANA AUTHORIZES ENFORCEMENT OF BASIC MEDICAID ELIGIBILITY REQUIREMENT- In the “wait- aren’t they already doing that department?”, LA has passed a bill (in the house only, still time to #Resist! in the Senate) that would allow the state auditor to review income tax returns to verify Medicaid eligibility. How dare they?

 

THE LAST FRONTIER TAKES LAST STAND AGAINST MEDICAID BUDGET IMPLOSION- AK Senator passed a work requirements bill this week to require about 10% of bennies to work. It will force pregnant women who are on crutches waiting in line for opioid treatment to work 100 hours a week. Just kidding you silly goose! All the normal exemptions are baked into this one. Track SB 193 if interested- here’s a link: http://bit.ly/2wdJ1Up

 

SEVERAL IMPORTANT ANNOUNCEMENTS:

 

• We released our HIPAA Awareness Online Course last week: http://bit.ly/2HzzUP1
• Medicaid Managed Care Congress 2018 | May 21-23 (Balto)- http://bit.ly/2vTwDZm
• 3^rd Annual Medicaid Managed Care Leadership Summit | June 4-5 (Chicago)- http://bit.ly/2HwGtlk

WELLCARE DOING WELL- Net income was up 51% YOY in Q12018 (now at $102M vs $67M for same quarter in 2017). While there’s a lot going on driving the success, expanding Medicare Advantage business is a big part of the story. There have also been decreased Rx costs in both its Caid and Care programs (not sure what drugs, or what programs have driven down costs – may be a good success story in there for some med-management / case-management program?). Finally, a lower tax-burden based on Evil Darth Trump’s tax cuts helped to increase the net income number as well.

SPECIAL SEGMENT THIS WEEK: FARRIS’S MEDICAID FAKE NEWS FOCUS- For years I have smiled at the immaturity of “newspapers” who publish “cutting Medicaid will kill babies” headlines. Now its just time to shame them. If some idiot can claim fiscal policy in modern America will kill babies when Medicaid is cut, then others can claim cutting education (surprise- because of runaway Medicaid spending done at the barrel of an emotional gun loaded with “cut my Medicaid budget and kids will die!”) will kill babies, too. Long wind-up. Winner of this week’s Lazy Thinking, Political Bullying Award goes to Detroit Free Press for “Here’s why Michigan Medicaid work requirements will kill people.” Pshaw. Save it for the White House Correspondent’s Dinner you hacks.

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. Shephard Spruill of Raleigh, NC got sentenced this week for stealing $6M from North and South Carolina Medicaid (2 states – impressive). David Johnson of Detroit was sentenced this week for his role in stealing $1.7M from Medicaid by billing under another dentist’s provider number for 3 years. Interesting fact about this one – once the PoPo was onto him, Johnson fled to the Dominican Republic to evade arrest and was picked up by federalis there. Mr. Spruill – you win this week’s award! (Not much by way of fraud this week. We must have fixed the problem last 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 (water some plants, cut grass. Enjoy that cut grass smell.) 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: Ny Ray dia naniraka ny Zanaka mba hamonjy izao tontolo izao

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2HV4gyM

For optimist readers- http://bit.ly/2HTz9nb

FRAUD FOLLIES THIS WEEK– Read until the end..

CUTS TO THE BUDGET IN RI? JUST KIDDING! Guvn’r Raimondo had thought about yanking $16M from the Caid budget this year, but hospitals squeaked loud enough to avoid it. It didn’t hurt that Congress made changes that appear to be bringing new life back into the DSH program, so the Good Guvn’r decided a fresh look at the proposed budget was in order. Good thing, too. Rhode Island is gonna need that extra cash to pay for services for enrollment increases that continue to surpass projections. The latest miss is about 6,000 more than the Govn’r planned on for the month of June (enrolled now already by April). But don’t worry – its mostly “federal dollars” (so for all you suckers living in states besides Rhode Island, you get to pay for it).

IDAHOANS TO VOTE ON EXPANSION- The expansion ballot initiative now has more than 56,192 signatures, so it looks like voters in The Gem State will get a chance to vote on expansion in about 6 months. 2014 estimates put Idaho “uninsured” at about 78,000. So if you assume each of those at a $200pmpm, that’s about $187M for annual costs for the new members the voters would be putting on the rolls. If Idahoans wanted to pay for it all themselves (instead of making you folks in other states with your “federal” tax dollars you contribute), and if only the 56,000 who got it on the ballot chipped in- then each petition signer would only need to write a check for $3,339 (each year). Or would you prefer to pay by credit card?

SEVERAL IMPORTANT ANNOUNCEMENTS- (Imagine my voice over the PA system in your elementary school when you were a kid):

 

• We released our HIPAA Awareness Online Course yesterday. You can check it out here: http://bit.ly/2HzzUP1
• Medicaid Managed Care Congress 2018 | May 21-23 (Balto)- I have lost count of how many times I have been to this one.. 10 years maybe? Would love to see you there- http://bit.ly/2vTwDZm

 

• 3^rd Annual Medicaid Managed Care Leadership Summit | June 4-5 (Chicago)- This will be my 2^nd year at this one. Had a great time last year- http://bit.ly/2HwGtlk

 

CONGRATS TO THE PLANS WHO WON IN THE SUNSHINE STATE- We all got the much-awaited news on this RFP Tuesday. Let’s congratulate colleagues in these plans: Sunshine State, Simply, Humana, WellCare (Staywell), FL Community Care, and Best Care Assurance (Horizon Health). Several incumbents got the axe, so expect the obligatory litigation to slowdown roll-out (Molina, Positive Healthcare, Prestige and Magelllan all were not invited back).

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. Ilya Babiner of Harrisburg, PA plead guilty to $1.5M in Medicaid dental fraud this week. He wasn’t very tidy with the false records, with silly things like 90% of his patients (that he didn’t actually see) having last names that start with “G.” His claims also contained unbelievable amounts of crown restorations and repeat dental services. Ronette Brown of Bridgeport, CT was found guilty this week for stealing $245k using her therapy business. She filed Medicaid claims for services that either were not provided, or were provided by unlicensed therapists through her business “New Beginnings Family Center.” Her co-conspirator would take 30% of revenues, and Brown got to keep 70% for her role in the operation.  Matthew Meyers of Knox County, TN plead guilty to Medicaid fraud totaling about $94k. Meyers worked in different clinics across the state as a nurse practitioner and used his doctor partner’s billing number to file claims for procedures he wasn’t licensed to perform. The Arc of Anchorage (an I/DD provider) settled for $2.3M with Alaska Medicaid this week. The Arc billed Medicaid for services not provided between 2012 and 2016. Mr Babiner- You win this week’s award!

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (mulch your tomatoes – trust me on this one) 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: Таткото го испратил Синот да го спаси светот

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2pQx6Gs

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

OPPOSING MEDICAID EXPANSION BECOMING GOOD IDEA IN OH GUVNR RACE- Now that the Good Guvnr Kasich has had his 15 minutes of fame, competition is piling on in the local race for the top seat in the Buckeye State. Two contenders – LT Guv Mary Taylor and AG Mike DeWine are now arguing over who was against Medicaid expansion first. The old I-was-for-it-before-I-was-against-it-because-it-used-to-be-popular line.

HURRY AND WAIT IN THE BEEHIVE STATE- The Good Guvn’r Herbert signed a Medicaid expansion bill in Utah this week. Now its time to see if CMS approves it. Predictions, anyone?

STATES CONTINUE TO FIND SUPPORT FOR REQUESTED FLEXIBILITY WAIVERS- I can’t even keep count of how many flexibility waivers have been filed now. While our wonderfully not-no-way-no-how-biased 3^rd estate use a broad-brush to paint all the waivers as evil “work requirements” schemes (imagine the Darth Vader march song right now), these requests include all types of things related to volunteer hours, reducing NET, changing how rx is paid for, et cet era (see the recording of our AZ state spotlight a few months back for a great example). Newer entrants this week include the Centennial State, where Colorado lawmakers are trying (currently stumbling) to get a bill through committee to modify its program. Minnesota lawmakers debated a possible flexibility waiver this week, too.

DEMS CARE ABOUT THE COSTS OF IMPLEMENTING A MEDICAID PROGRAM. HELL FREEZES OVER- In an unprecedented move, lefties now want to consider how much it will cost to implement new Medicaid program requirements. While this has never been an issue before, it seems the new flexibility waivers have clued them in to caring about implementation costs. Go figure.

OPIOIDS NEWS: IT JUST KEEPS GETTING WORSE- New research out in Pediatrics this month shows that Medicaid spent $2B on neonatal abstinence syndrome from 2004 to 2014. That’s babies born with opioid withdrawal, people. Not that I have any idea how much of the $2B is effective, waste, etc – all I know is it signifies how big and awful and evil this opioid thing is. Even before birth.

GOLD RUSH IN THE GOLDEN STATE: $740M IN MEDICAID SPENDING FOR INELIGIBLES (BUT DON’T WORRY THAT WAS 90% FEDERAL MONEY, SO NO HARM NO FOUL, RIGHT? CLASS- WHERE DOES FEDERAL MONEY COME FROM?)- CA enrolled 450k people that may have not been eligible, spending $738M on those who were definitely not eligible (and another $416M on those who were potentially not eligible). Check out the HHS OIG report here – http://bit.ly/2pQnvPL 

CONGRATS ERHARDT!- Erhardt Preitauer (currently of BCBS NJ) will be taking the helm at CareSource as CEO on May 1. Congratulations, Erhardt!

WEBINARS! WEBINARS! WEBINARS! We have had so many lately its hard to keep up. In addition to our regularly scheduled programming of News Roundtables, we also recently had Governor Matt Bevin of Kentucky. We have about a million shows coming up in the next few months, too. With everything from innovations in community engagement to ACOs in Massachusetts. Check the newsletter for schedules and times. And get there early if possible. We are in the process of upping our seat count, but until then only the first 100 people get in.

 

ON THIS DAY IN HISTORY- A little more than 2,000 years ago a first century Jew (who also happened to be God) was brutally tortured and murdered. He did this willingly so you can be with him (if you choose to). This is why today is GOOD Friday.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. No time this week, folks – but I am cooking up a quarterly fraud show. Would you attend? Let me know in the comments or via email..

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 a fruit tree) 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: De Papp huet de Jong geschéckt, fir d’Welt ze retten