Category: Clay’s Weekly Medicaid Roundup

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

For optimist readers-  http://bit.ly/2vyM3kT

 

MONDAY’S STATE MEDICAID SPOTLIGHT SHOW FEATURES PRESTON CODY, DIRECTOR OF WA MEDICAID PROGRAM INTEGRITY- After a long break, our State Spotlight show is back. Sign up free here if you are not already – http://www.mostlymedicaid.com/?page_id=1739

YOUR MEDICAID DRIVER IS 3 MINUTES AWAY- The Greater Buffalo ACO has inked a deal with Lfyt to carry bennies to their appointments. NET is a big, fat, tempting budget item that a small set of providers have had to themselves for years. I am amazed it took this long to “disrupt” this “market.”

PREZ USES BROAD DISCRETION BUILT INTO ACA AND HEALTHCARE POOH-BAHS CLUTCH PEARLS- Just kidding. Trump’s not doing crazy things allowed in ACA like suspending the individual or employer mandate during an election cycle (what kind of cynical, Machiavellian tyrant would do stuff like that?). In all fairness the whole CSR payments drama is a perfect analogue to the abuse of power that was set up nicely in ACA. He does really have them by the яйца (yaytsa if your pc doesn’t have the right font installed), doesn’t’ he? CMS is also encouraging states to submit waivers to alter the eligibility conditions (i.e. all the work requirements waivers you’ve been hearing about) and in some cases the benefit packages (ex: Iowa got approval to limit NET). #Resist!

UPDATE ON MA EMPLOYER FEE FOR MEDICAID- Covered this last week. Seems the outrage was less about forcing employers to cough up $750 per employee on Caid and more about daring to tie that to an expected effort to reduce spending. The Good Guvn’r has repented of this sin and now the deal simply taxes employers (a total $200M in new fees) and does not dare attempt the evil, hateful- dare I say it, Republican? – cuts (would have been $150M in Medicaid spending cuts tied to the tax). Forgot Draconian. APA style manual says you must use “draconian” when talking about Medicaid cuts.

THREE NEW STUDIES OUT ON MEDICAID AND KIDS- Good sumhttps://woocommerce.com/my-account/tickets/?id=605141mary at the AAP blog – http://bit.ly/2wruJLd . One looks at Caid costs by level of illness and concludes that a full 1/3 of all costs are for kids with chronic disease. The other 2 look at child ER super users and Rx costs.

 

CLEVELAND CLINIC ON THE REBOUND AFTER GETTING DUMPED- Seems CareSource OH ditched Cleveland Clinic from the network recently and it stung. So now CC has started dating Molina- this is the first time CC has been in network for Molina. CareSource and CC have said they will cement the break up if no agreement can be reached until Sept 1.

IF YOU LIKE YOUR MEDICAID INSURANCE, YOU CAN KEEP YOUR MEDICAID INSURANCE- A recent national survey found that Medicaid members gave their plans 78 more points than commercial members (out of a total of 1,000 points- 0.078% diff). So, when its free, its less than 1% more popular than something that costs an average of $5k + OOP when you do pay for it for a family of 4. Sounds awesome. Break out the champagne. Ready the confetti. Or maybe do all that you can to eliminate meaningful commercial coverage so there will be nothing to compare to and the peasants will accept whatever you give them all for “free”?

  

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. LaMar Taylor of Bowie MD was charged this week for scamming Medicaid out of $600k using his day-treatment services company to submit bogus claims. Bertha Blanco, an employee of the FL HHS agency was popped this week for her role in a $1B Medicaid fraud scheme. Her crime? In exchange for bribes, she helped a shady nursing home operator keep their license, which was easy since she was a state inspector. It was a slow week this week – only a few cases. But we did rack up $1.06B in tax payer loss. Quality, not quantity dear readers. Mrs. Blanco – you win this week’s award!

I WILL BE AT MESC IN 1 WEEK, WILL YOU? If so send me a note and let’s meet up.

I WILL BE AT MHPA 2017 IN OCT., WILL YOU? You can check it out here – http://bit.ly/2twCi5L Every 100th registrant will get a free Medicaid Foundations Course registration (our online training course).

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (tomatoes are finally red) 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: Sang Rama ngutus Sang Putra nylametaké jagat

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2vdvt9S

For optimist readers-  http://bit.ly/2v3Ugx6

 

CHECK FOR A PULSE-  Looks like Obamacare lives to skyrocket premiums another day (for those of us who still pay premiums, anyway). The Senate’s Skinny Repeal got shot down 51-49, with John McCain helping nix it along with two other Republicans. The night came with high drama, including a call from Trump to McCain (with Pence handing him the phone). McConnel is reported to have said “its time to move on.” My prediction: its done (at least for a long time).

 

BAY STATE BUSINESSES SUPER EXCITED TO PAY $300M IN FEES TO FUND INCREASING MEDICAID COSTS- Your reward as an employer in MA for providing jobs? Paying your employees’ healthcare costs AND $2k per employee to cover any Medicaid bennies on your payroll. Best. Plan. Ever. It’s a wonderful thing for politicians that 99% of Americans hated high school econ. The Good Guvn’r Baker’s plan is being scaled back, but not dead yet. If you want a vision of the future, imagine a boot stamping on a human face – forever. (Orwell)
TAKING IT UP A NOTCH- You know all those wacky states trying to add work requirements for non-disabled, non-elderly Medicaid bennies? Well if Senator John Kennedy of LA (cool name, rings a bell) has his way, Federal Medicaid regs will be changed to require it nationwide. Put this one on your watch list.

 

I WILL GLADLY PAY YOU ON TUESDAY FOR A HAMBURGER TODAY – IL finally started to pay some of the MCO tab last week – $750M in back payments went to plans. Now only about $3.5B more to go to get square. Reality is that which, when you stop believing in it, doesn’t go away. (Philip K. Dick)

 

ARKANSAS TRYING TO RESTORE COVERAGE FOR 2,000 IMMIGRANT CHILDREN EXLCUDED FROM MEDICAID BY BILL CLINTON- AR has about 12,000 Marshallese (The Marshall Islands) who got in under a 1986 law. Thing is Bill Clinton’s welfare reform (yeah, he did that) nixed any Medicaid coverage for them. AR DHS submitted a proposal to undo the Clinton coverage ban this week for the kids.

 

FLICKERTAIL STATE WILL COVER ABA FOR AUTISM- North Dakota Medicaid will cover applied behavioral analysis (ABA) for autistic children as of this week. Attempts by state reps to mandate commercial insurers in the state cover it were unsuccessful.

 

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. Tammie Sensenig of Denver, PA was sentenced this week to 4 years in prison. She already had a Medicaid fraud conviction, but lied about it and forged a background check when she got a new job as a behavioral health consultant for a company that provides Medicaid services. PA paid out $84k to the already-barred provider. Bharat Patel’s case this week in Norwalk, CT included video of him writing scripts in exchange for cash. He’s accused of stealing $4M from Medicaid by selling scripts to addicts. Meridian Senior Living Group in NC is being prosecuted for a $60M Medicaid fraud, based on comparing staffing levels to billable hours (hint -there’s not enough staff and too many billable hours). Meridian you win this week’s award by a mile! Total taxpayer tab this week: $64.8M. There was a lot more in Medicare but we stick to Caid here!

I WILL BE AT MESC IN A FEW WEEKS, WILL YOU? If so send me a note and let’s meet up.

I WILL BE AT MHPA 2017 IN OCT., WILL YOU? You can check it out here – http://bit.ly/2twCi5L Every 100th registrant will get a free Medicaid Foundations Course registration (our online training course).

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (It is nearly August and August is hot! Want to read Light in August with me? If 3 or more write in we’ll do a book club on it) 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: Chichi wa sekai o sukuu tame ni musuko o okurimashita

For optimist readers- http://bit.ly/2uxE8Re

 

Soundtrack for today’s RoundUp pessimist readers. On second thought, let’s do 2 optimist songs this week cause ‘Murica is awesome and its her birthday week- http://bit.ly/2uxG6Rs

 

DON’T FORGET MONDAY’S SHOW ALL ABOUT THE SENATE BILL- Alex Shekhdar of MHPA will take us all to school on what BCRA means for Medicaid funding. Sign up for free- http://bit.ly/2ccl593

SHAMELESS PLUG FOR OUR NEW ONLINE TRAINING COURSE: Check it out. We released it after years in the making. Here’s the video ad for it- http://bit.ly/2twQCeF

BADGER STATE HAS BUDGET SURPLUS- You’re not alone: I had to do a double take myself. Wisconsin will close out this SFY with Medicaid $325M to the good. Recipe for this fiscal success? Slower enrollment growth and more federal cash. Less spending and more “revenue” from Uncle Sam. Whooda thunkit?

 

LITTLE AMERICA ROLLS OUT 2 PROGRAMS TO FIGHT THE OPIOID SCOURGE- Maryland launched 2 new programs on July 1 aimed at getting ahead of the opioid epidemic. The first one deserves kudos because it targets how we got into this mess in the first place nationwide – Medicaid prescribing rules. The second one increases payments to residential substance abuse providers to help deal with the carnage. MCOs will be key partners, leveraging CDC opioid reduction guidelines.

 

LAND OF LINCOLN MUST PAY ITS BILL (SORT OF)- A federal judge ordered Illinois to pay its $3B Medicaid tab (the state has been stiffing providers and MCOs for quite a while). The court order has the state paying all new bills in full and on time, and establishes a payment plan of $293M in Medicaid back payments a month until its paid off. According to IL state Comptroller Mendoza, the new ruling “takes the state’s finances from horrific to catastrophic.” Don’t worry Mrs. Mendoza, I am sure the judge will point you towards the money trees so you can fix all this. (Hint – they are through that tiny little door in the back of Congress, in the small orchard in the back. The trees in the White House gardens have been out of order since November).

 

DENIZENS OF BLUEGRASS STATE MUST PAY THEIR OWN WAY (SORT OF)- The Good Guvn’r Bevin submitted a revised waiver request this week, looking to require bennies to work 20 hours a week if healthy enough to do so. This is up from the previous plan which had an increasing scale starting at 5 hours a week, walking up to 20 hours after a year of coverage. The new plan starts at 20 hours day 1 of coverage. Savings estimates mark the change at about $2.4B for KY by 2022.

 

SPELL WEARING OFF IN LAND OF ENCHANTMENT- Long-time readers may remember New Mexico cracking down on behavioral health providers accused of rampant overbilling of Medicaid (this was back around 2013, focusing on 15 facilities). Seems the state is walking back some of its claims (encouraged by a judge), and the attempted recoveries have plummeted from a total of $9.6M to $896k. Current finger pointing includes use of an extrapolated sample that did not have supporting documentation. One of the bigger issues is that Medicaid payments were stopped to these providers, causing disruption to members. Several of the organizations have been exonerated by the state AG. Good article on the details of this in the twitter feed (@mostlymedicaid).

 

NATURAL STATE ROLLING IT BACK- Arkansas submitted its request this week to modify its magical waiver (the one where they put expansion bennies on the exchange). Changes include knocking eligibility back down to 100% FPL (it was 138% to get the ACA cash), adding work requirements for those deemed healthy enough to work, and ending an employer-sponsored premium subsidy 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. TN is taking Med Management, Inc (MMI) to court for $7M in bogus claims for pain management. John H. Johnson of Hollidaysburg, PA faces 7 years in the slammer for his role in a patient-referral kickback scheme that stole $1.1M from Medicaid. Johnson sent Medicaid members to Universal Lab for tests in exchange for kickback payments. Dawn Bentley of Detroit was sentenced this week for her role in a $7.3M Care and Caid scheme. She providing billing services for bogus physician claims in exchange for a 6% cut. He biggest client- Waseem Alam- plead guilty last year to a $33M take. Anna Young of Chadron, NE must pay back $309k after admitting to billing $102k without sufficient documentation for her mental health services (she has to pay back 3 times what she stole). Mrs. Bentley – you win this week’s award! You are the first biller I have come across offering a fraud outsourcing service. Kudos!

 

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 (cook out again this weekend- celebrate the 4^th twice!) 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 Padre ha mandato il Figlio a salvare il mondo

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2u5LKtU

For optimist readers- http://bit.ly/2u2PRXL (a poppy bit for your vacation trip)

 

SHAMELESS PLUG FOR OUR NEW ONLINE TRAINING COURSE: Check it out. We released it after years in the making. Here’s the video ad for it- http://bit.ly/2twQCeF

I WILL BE AT MHPA 2017, WILL YOU? Chairing a Medicaid Director’s panel. Would love to see you there. You can check it out here – http://bit.ly/2twCi5L

DETAILS OF THE SENATE BILL THAT WILL KILL EVERYONE 4 TIMES OVER AND ALSO INCREASES CLIMATE CHANGE AND ALSO EVERY OTHER BAD THING WE CAN TACK ON TO THIS BILL THAT STOPS THE SPENDING ORGY WE HAVE ALL ENJOYED FOR DECADES, UNINTERRUPTED (BUT WE LOOKED NOBLE DOING IT, AND ALWAYS CLAIMED MORAL SUPERIORITY, SO WE’RE TOTES GOOD, RIGHT?) – Long headline, short link to good analysis on the timeline for the BCRA funding changes: http://bit.ly/2u1CDKM  Here is another one that compares the House and Senate bills in case you are into that sort of thing: http://bit.ly/2twMXxs

 

YEAH, BUT HOW DID WE GET HERE? As part of the frenzy to show what all problems Medicaid can solve, DJs have put the “Caid can solve the opioid crisis” EP back into the rotation. My suspicion is if you look at a chart oxycontin, et al volume over the last 20 years and slapped a category for payer on it that Medicaid funded the current opioid crisis. Am I crazy to think this? Write in and do tell.

 

IT’S THE BIG ONE, ELIZABETH! Please tell me you get the reference. Assuming you do, I am suddenly struck by the richness of what we all share via pop culture. Anyways… OR Caid has studies out now showing a 17% drop in cardiac arrests after expansion. Once patients got an insurance card in their pockets, they delayed care less and had that chest pain checked out.

 

MCOS IN ILLINOIS: MAY NEED TO WRITE THIS ONE OFF ON YOUR TAXES- IL State Attorney Stratton told a judge this week that the state simply does not have the cash to pay its Medicaid costs (as was asked by a recent Medicaid member lawsuit in response to the state not paying providers and MCOs). The lawsuit asked IL to pony up $500M more a month to get caught up. Stratton says the state may be able to come up with $150M a month for the pay-your-freaking-tab effort. Fortunately, healthcare superheroes from CA and NV flew in and paid for it out of their own pocket (they had a ton left over once their single-payer bills failed last week). Just kidding, we all know Bernie wrote the check.

 

SHOW ME STATE WANTS TO UN-SHOW EXPANSION- MO reps voted to freeze Medicaid enrollment in the expansion group to try and help deal with their budget crisis. All analysts expect this to trigger a fight with the Good Guvn’r Kasich.
CENTENE GOES ON PROBATION IN THE CORNHUSKER STATE- Seems the state is unhappy with the plan’s troubles getting behavioral health and home health providers paid.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Rabbi Zalmen Sorotzkin of Lakewood, NJ was popped this week for leading a $1M fraud bilking Medicaid and other benefit programs. Cheryl Mcgrath of Guysville, OH plead guilty this week to using her home health care company steal $2M from Medicaid via false claims, including for dead people or people in nursing homes at the time she claimed to be providing home health services. Anthony Handal and his fiancé Sandra Mora of Orlando, FL billed Medicaid for $160k of intensive family case management services they never provided. They would conduct an initial meeting with the Medicaid-enrolled families to get their member numbers, then never do anything else to help them (but billing FL Medicaid for 3 sessions a week for the family). Collins Anyanwu-Miller of Bridgeport, CT was arraigned this week for stealing $390k from Medicaid by falsifying home care claims. Mr. Anyanwu-Miller even managed to get paid for home care services that occurred while he vacationed in Europe. Mrs. Mcgrath- you win! (Taxpayers, you lose! Total tab this week: $3.6M).

 

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 (when the rain stops) 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: an tAthair chuir an Mac a shábháil ar fud an domhain

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2szI2LI (Pray for our nation. Even if you don’t believe in prayer. Or our nation. We gotta make as much noise as we can in the desperate hopes that He will hear us.)

For optimist readers- http://bit.ly/2szB7Sr

 

 

SHOUTOUT TO MY SOA PEEPS- Great time with my actuary friends at the SOA Health Meeting in FL this week. Thanks again to everyone for making it another great experience!

 

 

I’LL TAKE MINE WITH SPRINKLES- In case you haven’t heard, a rep from NV has thought of something none of us have in the 50+ years of the program: Medicaid for All! This is such a great idea, but why stop there? Why not Medicare for All (paging Dr. Sanders)? Or TriCare for All? Or BlueCross Blue Shield for All? If I would have known I can just append the magic words “For All” to something and get stuff without worrying about pesky things like costs, actual eligibility requirements and, oh, I don’t know, general freakin’ stability- I would have been namin’ and claimin’ it years ago (paging Dr. Osteen). Ferraris for All…Checklist of questions before you get starry-eyed on this one: What will be the FMAP (will there be FMAP)? Will provider rates stay at Medicaid rates? Will this be done with a State Plan Amendment, or an 1115 Waiver? Do you think CMS will approve either? Or, are you thinking NV is so serious about this, it will do it all with state-only dollars? What percent of individuals (now that the individual mandate is likely gone) do you think will choose to “buy” Medicaid on the exchange (would you buy Medicaid if you had a choice)? How will the subsidies for this one work? Will anyone buy it without a subsidy? If the state is selling coverage (Mike Sprinkle’s plan) and calling it Medicaid, is that actually Medicaid? Is the state now an MCO and subject to MLR rules, MCO taxes, etc? Hashtag: ImportantQuestions.

 

GOING, GOING, GONE! Any hopes that expansion costs would ever flatten out, that is. New data shows state expansion costs in 2018 will be $8.5B- more than a 100% increase over 2016. Some of this is that the tab is finally come due (states started paying a % of costs this year), but a lot of it is states’s eyes were bigger than their stomachs and expansion costs a LOT more than dreamers ever dreamed.

 

MEDICAID IN THE GOLDEN STATE FOR EVERYBODY? NOT SO FAST- CA reps dropped plans to give Medicaid to all undocumented persons in the state. There were plans to use tobacco taxes to cover the initiative, but seems those $s will instead go to increase Medicaid provider rates.

 

SOONER STATE WILL PAY DOCS LATER RATHER THAN SOONER- OK Caid officials have proposed to float payments to providers by a month in order to not decrease rates. Not sure I understand the overall logic, so write in if you know more. Scarily similar to what we wrote about last time re: IL being $2B behind in Caid payments.

 

BEAVER STATE GETS NEW TAXES TO FUND CAID HOLE- OR reps passed a new $550M tax on hospitals and health plans to avoid Medicaid cuts. The state faces a $1.4B budget hole (not just Caid).

 

HEALTH HOME PROVIDERS BEG FOR MORE BREAD IN THE BEEHIVE STATE- Home health aides now have better employment options with the upturning economy, and Utah home health agencies are asking for more Medicaid funding to be able to pay employees more than their other options.

 

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Alan Nisselson of the Bronx plead guilty this week for his role in a $27M false claims Medicaid fraud conducted by his company Narco Freedom. Elizabeth Powell of Helena, MT plead guilty for her role in a $450k Medicaid fraud involving physical therapy claims. She got her family to say they were getting PT and then diverted the payments out of the physical therapist’s bank account. Kester Atumonyogo of New York was indicted for stealing $1M with a nutritional formula fraud. Mr. A used a stolen SSN to enroll his DME company (Monack Medical Supply) and then started billing MCOs like mad. Robert and Kristina Corrado (father and daughter) of Nesconset, NY stole $2M from Caid using a kickback scheme that provided housing to homeless people only if they agreed to get treatment at their substance abuse treatment center. Wilbert Veasey, Jr. of Dallas, TX was sentenced to 17 years for his role in a $400M home health fraud ($500k was Caid, $22M was MediCare). Kathleen Tuorila of Del Rio, TX was sentenced this week for her role in a $3.5M DME Medicaid fraud. She helped submit false claims for power wheelchairs. Total taxpayer tab this week: roughly $57M. Congratulations, Alan- You win!

 

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (Weeds everywhere!) 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 mengutus Anak untuk menyelamatkan dunia

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2rMf8Yi

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

 

I SEE CHICKEN LITTLES (READ THAT IN HALEY JOEL OSMENT’S VOICE FROM THE 6^TH SENSE)- For all those screaming that the Medicaid world is ending, please see my article last week “A Few Charts re AHCA and Medicaid” (http://bit.ly/2rM9Pbl). We were flying the plane 90 degrees straight up (into the white hot burning sun); now its tacking at about 87 degrees. If you are going to freak out about the “cuts” at least be honest and use the real numbers. Any corrections to my #s / charts much appreciated. Send me a note and I can send you the spreadsheet and we can revise together. It would be like a group project in highschool.

 

SEEMA SAYS- An interview with CMS chief Seema Verma came out this week in USA Today, which is pretty cool because the recently former acting CMS Admin Andy Slavitt (now turned townhall superhero/the Michael Moore of Healthcare) is sort of on staff at USA Today as well. So, balance I guess. Anyway, Seema says that whole state-fed partnership thing is really out of whack in favor of top-down D.C. bullying, and its time for the states to have some actual say in the program, even if it means occasionally going against the D.C. money dealers. Somebody pinch me.

 

SAGEBRUSH STATE SEEKS TO EXPAND- Mike Quixote, er I mean Sprinkle, submitted a bill to expand Medicaid in Nevada this week. Good luck, Mike. Let us know how it turns out!

 

AMERICA’S DAIRYLAND ASKS YOU TO PEE IN A CUP- Wisconsin legislators approved the Good Guvn’r Walker’s drug testing provision for Medicaid coverage this week. Now it just needs to get covfefe-ed by President Trump’s CMS Administration.

 

PRAIRIE STATE SLOWING DOWN MCO STRATEGY- Dems in Illinois passed SB 1446 to require the state to use the normal procurement process in its attempts to expand managed care. Seems current state DHS officials have been using a different process (but not a new one), and legislators think it should be more transparent.

 

THE MUSIC HAS STOPPED AND MEDSTAR DOES NOT HAVE A CHAIR- D.C. MCO awards are out, and MedStar (an incumbent with about 60k bennies) is on the losing list. Per the D.C. report, MedStar had 40% higher costs and a higher service denial rate. MedStar responded that their bennies needed more pharma, but it wasn’t enough to sway the judges. Winners include Trusted Health Plan, AmeriHealth Caritas, and Anthem. Congrats to all our colleagues in the winning MCOs.

 

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.  Ronette Brown of Bristol, CT was convicted this week for $200k worth of bogus psych therapy. Barbara Wallace of Savannah, GA was sentenced to 41 months for stealing $948k from Medicaid. Her crime? Selling unnecessary medical shoes. Complementary Support Services of Minnesota settled its Medicaid fraud suit for $4.5M. CSS was a mental health provider that fabricated patient records to get paid. Sonia Ponce of Freeport, NY stole $75k by inflating home healthcare aide time sheets under the state’s Consumer Directed Health Program. Total taxpayer tab for this paragraph: $5.8M. CSS you 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 (Everything is sprouting!) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Nna zitere Ọkpara ịzọpụta ụwa

 

HOUSEKEEPING – A few quick items: Here’s a link to my current thoughts on the impact of AHCA, current as of Thursday (after the 2^nd CBO report)- http://bit.ly/2rm9tro

Also, I am joining some of my friends at Matrix Healthcare to do a webinar for RISE next week. All about quality withholds in Medicaid. You can sign up here (If you’re a RISE member it’s free, else it costs)- http://bit.ly/2r9BRgl

 

“People Sleep Peacefully in Their Beds at Night Only Because Rough Men Stand Ready to Do Violence on Their Behalf”- This is our annual time here in RoundUp Land (and in all the U S of A) to remember those who have died to protect our rights as American citizens. Memorial Day (Monday) honors the men and women who died while serving in the U.S. military. It is NOT the kickoff party for summer, but they died so that we idiots could have freedom to think even stupid things like that. Please take a moment to remember them grill-side on Monday as you enjoy the blessings made possible by their sacrifice.

 

Service Members Who have Died in MAY 2017 AS OF THE 25^th

 

Senior Chief Petty Officer Kyle Milliken. Died May 5, 2017 Serving During Operation Iraqi Freedom. Hometown: Falmouth, Maine.

 

Service Members Who Died in APRIL 2017

 

1st Lt. Weston C Lee. Died April 29, 2017 Serving During Operation Iraqi Freedom. Hometown:

Bluffton, Georgia.

 

Sgt. Joshua P Rodgers. Died April 27, 2017 Serving During Operation Freedom’s Sentinel. Hometown: Bloomington, Illinois.

 

Sgt. Cameron H Thomas. Died April 27, 2017 Serving During Operation Freedom’s Sentinel

Hometown: Kettering, Ohio.

 

Staff Sgt. Mark R De Alencar. Died April 8, 2017 Serving During Operation Freedom’s Sentinel

Hometown: Edgewood, Maryland.

 

 

See more heroes @ http://thefallen.militarytimes.com

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FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Faðirinn sendi soninn til að bjarga heiminum

Soundtrack for today’s RoundUp pessimist readers (technically a movie clip this week)- http://bit.ly/2rvupJk

For optimist readers – http://bit.ly/2rvJIC0

 

IS THIS THING ON? As is our custom here in Roundup-Land, after a long hiatus (client work, gardening), I make it up to you by starting off with the Fraud Follies instead of saving them until the end. But this time, there’s a catch. I translated this week’s Farrises Fantastic Fraud Follies into Russian. You have to take an extra step and use Google Translate to get it back to English (or your preferred language). Do you give up now and move on to the next quick blurb in your news feed? Are there secret messages and memos in this week’s roundup? Leaks, even? You will never know unless you head on over to Google Translate and paste this puppy in there now. NOTE: I have also reverse-translated and there are some good transliterations that happened. Some things get lost in translation. Some things get better. I am excited for you about this. Here’s the link to Google Translate: https://translate.google.com/

 

И ТЕПЕРЬ МОШЕННИКИ СЛЕДУЮТ, ТОВАРИЩИ – Ахад Лотфи из округа Ван Бурен, штат Мичиган, был на этой неделе в суде за обвинения в мошенничестве, связанные с заказными вкладышами для обуви, проданными в его клиниках хиропрактики (всего украдено- 200 тыс. Долларов). Цезарь Тавера и Андрес Айала из Черри Хилл, Нью-Джерси признают себя виновными на этой неделе в мошенничестве с Medicaid. Их преступление? Кража $ 1.5M от Medicaid с использованием их ролей в некоммерческих целях местного сообщества. Г-н Тавера хорошо провел время – в одном случае он снял 35 000 долларов с банковского счета некоммерческих организаций, находясь в казино. Огайо получит 447 000 долларов США от CareCore как часть мультигосударственного урегулирования. Кажется, CareCore платит всем, чтобы перестать приставать к ним об обвинениях, которые они планировали, чтобы автоматически одобрить радиологические тесты, которые не были необходимы с медицинской точки зрения (CareCore – это компания, предоставляющая льготы, и они должны выплатить всего 54 млн долларов). Ев-Грей из Чикаго признал себя виновным в краже 7 млн ​​долларов от Medicaid, работая с электронным заявлением о медицинской записи, которое помещало законсервированный язык в медицинские документы, чтобы удостовериться, что Medicaid заплатит (они становятся умнее, люди). Мистер Грей – Вы выигрываете награду на этой неделе! Ваши очки за инновации привлекли вас к вершине.

 

A FEW OTHER QUICK HITS-  Oregon said it may have spent hundreds of millions on members who were not eligible. Info still coming in on this one so probably smart to be patient. The California Medicaid expansion bill comes due this year, and its $1.3B in state funds for 2017. Several incumbent Illinois MCOs did not submit proposals on time for the new awards and won’t be in the race. After a ton of pressure, PA Medicaid will cover HeP C miracle drugs. BCBS and Amerigroup got hitched in NC in prep for the inevitable managed care switch there. Oklahoma is considering pulling plans to bring managed care in. And Ohio is trying to find $600M now that the federalis have said they can’t tax MCOs anymore.

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (I need rain, do you need rain?) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Apa elküldte a Fiút a világ Megváltójaként

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2owUh57

For optimist readers – http://bit.ly/2ox20jq

 

 

MY KIND OF TOWN- Had a GREAT time at the HEA-RISE MMC Leadership conference this week in Chicago. Looking forward to next year. And to Balto next month with the MMC Congress. Will I see you there?

 

 

THE (EGADS!) CONSERVATIVE FEATURES IN EMERGING MEDICAID TRENDS (DOES ANYONE HAVE ANY HOLY WATER?) I have been around this Medicaid game long enough to know the war over Medicaid spending is a war of attrition and anything that even smells slightly conservative loses in the end because of lack of sustained interest on the conservatives’ part and vehement “resistance” on the liberals’ part. That being said, there are many signs if you care to read the bones: Every week a new state announces waiver plans with job requirements. Wisconsin was the latest- and it added drug testing and premiums. Maine announced similar plans (they linked food stamps to work already). Arizona is considering a 5-year lifetime enrollment max for the “able-bodied” (super slippery word all around) as well as work requirements.

 

 

OREGON MAY BE THROWING IN THE TOWEL ON EXPANSION- Dems – I repeat Dems – in OR are proposing Medicaid be un-expanded. Why? you ask? Because the state is short $1.6B.

 

BUT ON THE OTHER HAND, NC MAY BE GETTING CLOSER TO EXPANDING- Republicans – I repeat Republicans – introed HB 662 this week to start the process of funding expansion using federal dollars. GOP leadership in both the NC House and Senate remain opposed, but hey – these Repub Resisters deserve some props, right?

 

CMS WILL “REVIEW” MONTANA’S EXPANSION- This situation is sort of like when you see the cops at the precinct get a visit from Internal Audit. CMS approved MT’s expansion in 2015 and had high hopes for adding 70k under the spreading wings of Mother CMS. What is the crime that brought in Internal Audit? MT charges 2% for premiums to bennies above 50% FPL. And copays. So, CMS is sending in sleuths to “evaluate” the program (take a gander at how many other waivers ever get evaluated, vs just renewing the “demos” for decades on autopilot). The real goal is to get a ton of negative public comment to pile on to the program and insist a mandate for change has been discovered. Keep in mind the same thing happened to IN last year (a post-CMS approval PR campaign ala a surprise round of public comment-y evaluation against the “conservative” model once they saw other states following IN’s lead).

 

MISSOURI SAYS NO TO EXPANSION- While some had high hopes for the Show Me State this year, and a proposal was introduced, sources say no dice.

 

SO DOES NEBRASKA- The committee that reviewed the expansion proposal in the NE legislature politely declined this week. Would have added about 90k to the rolls.

 

CLAY GETS TIRED OF WRITING EXPANSION HEADLINES- Aren’t you tired of reading them? How about a video about Atlantic Mole Crabs instead http://bit.ly/2oxf9sL ?

 

LOW CAP RATES MAY SCARE OFF MCOS? Says the headline. What are they gonna do – go back to the exchanges? Ha! (imagine that Ha! being said by A.L.F.)

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph… but not enough space this week, Dear Readers. Had to catch you up on a ton of news. I put lots of Follies in the twitter feed for you this morning, though. My favorite is the former NY state legislator who was charged with running a Medicaid pill mill scam. Check them out and tell me your favorite.

 

 

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 (don’t forget mulch for your baby plants!) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Leej Txiv tau xa Leej Tub kom txuag lub ntiaj teb no

 

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

For optimist readers –  http://bit.ly/2nk2ZDg

 

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

 

STATE SPOTLIGHT SHOW NEXT WEEK CHANGED TO “OFFICE HOURS WITH CLAY”– State Medicaid Directors are all locked in cages in basements of legislatures this time of year. Something about “budgets.” So for those of you who want to show up for the Friday 4/7 show we will keep it and I will field whatever questions you want to throw at me re: Medicaid.

 

BROWNBACK SAYS NO DICE– Kansas reps got the votes together to expand, but the Good Guvn’r said not on his watch. He said the proposal would not help the “truly vulnerable” but instead would surge state spend on the “able bodied.”

 

SHOW-ME-STATE SHOWED THEM- Reps in MO soundly rejected efforts at Medicaid expansion this week, with the house voting 102-41 against. Seems the Russians paid fake news bots to force representatives to vote against their will on this one.

 

VA IS FOR LOVERS (AND LOST CAUSES)- The Good Guvn’r McAuliffe thinks the failure of RyanCare was his cue to restart expansion efforts. His GOP colleagues in the legislature politely reminded him they rejected expansion in 2013, 2014, 2015, 2016 and once already in 2017. Seems they don’t intend to stop their streak.

 

ALL JOKING ASIDE– Conventional wisdom is that more states will expand now that RyanCare failed bigly. KS and NC are expected to be next (Brownback may have some unilateral options left?). And GA, ID, NE and SD have been on the fence for years. Here’s a fun twist- 1132 waivers. They just got turned on January of this year, and could be a legislative-free path to changing ACA so much you don’t recognize it. Remember you heard it here first. 1132 waiver. Google it.

 

IOWA TAKING STEPS TO MAKE MCOS WHOLE- MCOS have claimed a combined loss of about $450M, and details about the state’s plan to stop the bleeding emerged this week. Looks like the state will chip in $10M more and the federalis $225M more to help MCOs cover losses since the state moved to manage care 1 year ago.

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.  Christina and Donald Halter of St Francois County, MO were convicted this week for stealing $209k in disability payments from a developmentally disabled vet in their care. Oh yeah – they also submitted 1,000 false Medicaid claims for nursing services not provided to other residents of their facility. Isnino Mohamud, Mowllid Nur and Ayan Barsug of Minnesota were charged this week for conspiring to defraud Medicaid out of $1M. Their crime? 2 of the guys would submit false bills for transportation of patients to the other guy’s place, where he would then provide counseling services. Problem was they were billing for individual sessions, but it was really happening as group therapy. Apparently Mohamud and Nur also recruited patients who spoke little English and had Medicaid cards. “Dr” Roberto Fernandez of Miami got popped this week for taking kickbacks from local pharmacies and home health agencies as part of a Medicaid (and Medicare) controlled substance fraud scheme. Taxpayer tab on this one so far – $20M. Messiuers Mohamud, et al- you win the day (but only b/c Bob-O Fernandez’s heist spanned Care and Caid. You had a clear Caid-only assault).

 

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 (You still have time to move bulbs.) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: pita ne duniya ko bachaane ke lie putr bheja