Posted on

Medicaid Industry Who’s Who: David Evans

Medicaid Who’s Who: David Evans – VP of State Government Programs with Geisinger Health Plan in PA

  1. What segment of the industry are you currently involved? 

A:  I currently am responsible for the 175,000 plus Medicaid members in the MCO where I work.  I am also responsible for approximately        10,000 CHIP members. 

  1. What is your current position and with what organization?

 AI am the VP of State Government Programs for the Geisinger Health Plan in Pennsylvania.

  1. How many years have you been in the Medicaid industry?

 A: Although I have been in the healthcare industry for over 30 years (half of which have been in managed care), I have only been involved in the Medicaid portion for the last 4 years.

  1. What is your focus/passion? (Industry related or not)

A: For most of my healthcare career I have been involved in quality and process improvement in one form or fashion.  That is why I jumped at the opportunity 4 years ago to move into the Medicaid industry, to take my quality experience into a new line-of-business for Geisinger Health Plan at the time.

  1. What is the top item on your “bucket list?”

ATo spend time in Alaska.  I love the outdoors and that would be the ultimate for me.

  1. What do you enjoy doing most with your personal time?

 A: Fly fishing. Nothing beats the quiet and solitude of standing in a trout stream fly fishing. 

  1. Who is your favorite historical figure and why?

 A: Abraham Lincoln.  Certainly regarded as possibly the best US President, Lincoln’s humane personality and democratic eloquence are what makes him stand out among all political figures. 

  1. What is your favorite junk food?

A: Pizza, although I don’t consider it a junk food.

  1. Of what accomplishment are you most proud?

A:  Starting to work with the Geisinger Health Plan at the infancy of NCQA Accreditation and HEDIS reporting and helping to build that program into one of the top 10 Commercial programs in US is an accomplishment I am very proud of.

     10. For what one thing do you wish you could get a mulligan?

A: In reality nothing.  I have certainly made some mistakes over my life and career, but I would rather learn from them and move on than attempt a do-over.

  1. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months? 

 A: Although there are a number of issues that are impacting Medicaid currently, for me personally, building a service oriented program for Managed Long Term Services and Supports will be the most important.  Pennsylvania is moving MLTSS into managed care and Geisinger Health Plan will be ready. 

 

To ensure that you’re in the loop on all things Mostly Medicaid, be sure to sign up to receive our free newsletter, join the discussion on LinkedIn and check out tons of great content at www.mostlymedicaid.com.

Posted on

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

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

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (I got lemongrass plants on clearance for $1 this week!) and keep running the race (you know who you are).

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

 

News that didn’t make it and sources for those that did: twitter @mostlymedicaid | Otac je poslao Sina da spasi svijet

Posted on

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

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

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

 

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

 

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

 

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

 

News Item 1

Supplemental rule

Leaves OMB, goes to Prez

Cash this way rising

 

News Item 2

Bad times for Alere

Investigation slows buy

Kickbacks, fraud – oh my!

 

News Item 3

BlueGrass state looks back

Before leap, before Beshear

Plays chicken with feds

 

News Item 3

Public option lives!

Policy wonks remember

Prez gave C-P-R

 

News Item 4

Wolverine State plans

In the money, man oh man!

ACA cap rates high?

 

News Item 5

Brandstad marches on

Tells Dems and press to stuff it

Growing pains, he says

 

News Item 6

Anthem beats forecast

CIGNA deal still taking time

But rolls grew half-mill

 

News Item 7

UHC, Aetna

New Cal-forn-ya MCOs

Congrats on the win!

 

News Item 8

Caid’ Rx report

Abilify, Sovaldi

And Vynase top list

 

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (its time to start planting a second crop!) and keep running the race (you know who you are).

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

News that didn’t make it and sources for those that did: twitter @mostlymedicaid
lu Patri mannau u Figliolu di salvà u mondu

Posted on

Medicaid Industry Who’s Who Series: Thomas Novak

Thomas Novak is a featured panelist for the upcoming “New Medicaid Health IT Funding and CMS Guide” Webinar on August 15th. RESERVE your seat today!

 

Medicaid Who’s Who: Thomas Novak – Medicaid Interoperability Lead with the Office of the National Coordinator for Health IT

1.   What segment of the industry are you currently involved?

A: I help build Health Information Exchanges at the state level. The state Medicaid agencies have a lot of carrots and a lot of sticks they can use to drive statewide interoperability in efforts to improve outcomes and control costs and it can be difficult to think through strategy of funding streams, sustainability, standards, architecture, and which use cases actually move the needle on outcomes and cost. I provide a lot of direct support to states to help where needed.

2.   What is your current position and with what organization?

A: I am the Medicaid Interoperability Lead with the Office of the National Coordinator for Health IT. I am also detailed 50% to the Medicaid Data and Systems Group at the Centers for Medicare and Medicaid Services. Sitting (virtually) in both places allows me to really manage state level interoperability efforts.

3.   How many years have you been in the Medicaid industry?

A: 16 years. I have had the opportunity to be on all sides of Medicaid. My wife practices pediatric emergency medicine so I’ve moved around a lot as she’s gone from medical school, to residency and fellowship, and now attending. I started at the state level working with Massachusetts’ Uncompensated Care Pool and then rolling out their HIPAA transactions. I spent several years at Health Partners of Philadelphia, the largest urban MCO in Philadelphia. There I worked in Complaints and Grievances as well as helping coordinate plan-wide NCQA accreditation and ran some of our leased networks; all roles that really exposed me to all aspects of Medicaid’s processes. Finally, my provider experience was as the Director of Quality for the AIDS Resource Center of Wisconsin, the largest HIV agency in the state. There I had great support from the CEO and Medical Director who set me loose to see if I couldn’t get us to be the first HIV clinic recognized as a patient-centered medical home in the country by NCQA and we did it, and received enhanced Medicaid support as a result. And finally, I have been with the federal government for over 5 years now. I helped launch the Medicaid Meaningful Use program and supported most of the east coast states, as well as did a lot of work on the regulations and I have now settled into Health Information Exchange as my primary policy focus.

4.   What is your focus/passion? (Industry related or not)

A: I truly believe we can save lives by putting the right information in front of the right provider at the right time. The complexity involved in doing as such thoughtfully is attractive, and will be a career well-spent, I believe.

5.   What is the top item on your “bucket list?”

A: Aside from building a health information exchange in every state and territory that serves the needs of Medicaid patients,  I do think it would be nice to get back to running. I’ve ran two marathons but my wife and I now have four daughters aged five and under, which is clearly a joy, but carving out time for training is essentially impossible.

6.   What do you enjoy doing most with your personal time?

A: I really enjoy cooking. I have a smoker and a sous vide and various other devices. Whenever I have free time I tend to come up with a fun recipe to try out. Spending an afternoon listening to music, with a glass or two of wine and cooking is probably my favorite leisure activity.

7.   Who is your favorite historical figure and why?

A: Marquis de Lafayette. Sure, he was somewhat just an impulsive post-adolescent, but he abandoned his nobility and sailed across the ocean to support this great experiment of democracy and we arguably owe our freedom to his passion.

8.   What is your favorite junk food?

A: I tend towards savory rather than sweet. As I am half Mexican I have to say chips and salsa. Specifically, chips and salsa from Jacobo’s in Omaha, Nebraska, my hometown.

9.   Of what accomplishment are you most proud?

A: Being a good father to my daughters, of course. But the work behind our State Medicaid Director’s letter (16-003) supporting interoperability for more Medicaid providers (long term care providers, behavioral health providers, substance abuse treatment providers, etc.) was such a satisfying achievement. My youngest twin daughters were born 3 days before it was published, and though I thought, “It’s like we both gave birth!” was a solid joke, my wife never quite agreed.

10.  For what one thing do you wish you could get a mulligan?

A: I think we could have spent more time facilitating the workflow conversations around Health IT. The Regional Extension Program was demonstrably successful in helping with providers adopting Electronic Health Records, but providers who were not fortunate enough to be connected with a regional extension center may have never received that hands-on support. A sizable number of complaints about EHRs are really complaints about workflow. There might not be someone who took the time to sit down and talk with the provider before implementation, ask about his or her workflow, and then implement the EHR in a way that meaningfully improved efficiency and quality of care.

11.  What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months? 

I’ll answer in terms of health information exchange as I can’t help myself:

A.  Public Health Architecture, specifically how Medicaid can respond to Zika, lead exposure or other state priorities. The SMD 16-003 supports states in the architecture and on-boarding to specialty registries, which are part of Meaningful Use. These sorts of systems are integral to whatever case management we need to develop  to address these conditions and those systems can now be supported. States are also thinking of specialty registries in ways that really bring innovation into the Medicaid enterprise. We have states looking at building homelessness registries, registries for school based clinics, advanced directive registries, all great ideas.

B.  On-boarding sounds vague but really is that missing piece hindering semantic interoperability in many cases. A state bringing in a someone to work with a provider on integrating the health information exchange data into his or her workflow and making sure that they are not simply connected to the HIE, but there has been testing and production data exchanged. There’s also the crucial administrative work that on-boarding involves. Looking at contracts. Looking at consent models. Looking at Business Associate Agreements. Looking at encryption standards. Coordinating these things truly gets data moving.

C.  I’ll group encounter alerting and care plan exchange together and they’re the best tools for the really aggressive case management you need in Medicaid to support those with multiple chronic conditions, the super-utilizers, if you will. Knowing where your patients are and are not, and coordinating their care is so critical and not only improves outcomes, but truly moves the needle on costs.

 

To ensure that you’re in the loop on all things Mostly Medicaid, be sure to sign up to receive our free newsletter, join the discussion on LinkedIn and check out tons of great content at www.mostlymedicaid.com.

Posted on

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

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

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

 

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

 

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

 

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

 

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

 

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

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (or maybe stay in- its HOT!) and keep running the race (you know who you are).

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

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

Fùqīn sòng érzi lái zhěngjiù shìjiè

Posted on

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

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

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

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

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

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

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

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

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

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

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

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

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

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

hkamaeetawsai kambhar  kaalhphoet  sarrtawko hcay lwhaattaw muu

Posted on

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

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

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

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

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

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

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

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

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

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

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

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (the sun is up earlier now!) and keep running the race (you know who you are).

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

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

Otets prati Sina , za da spasi sveta

Posted on

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

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

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

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

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

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

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

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

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (the sun is up earlier now!) and keep running the race (you know who you are).

—-

FULL, FREE newsletter: http://eepurl.com/ep81Y

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

Otac je poslao Sina da spasi svijet