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Clay’s Weekly Medicaid RoundUp: Week of September 3rd 2018

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

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

 

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

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

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

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

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

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

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

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (start chopping firewood. I predict a real winter this year) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Pitā nē jagata nū bacā’uṇa la’ī putara nū bhēji’ā.

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Clay’s Weekly Medicaid RoundUp: Week of August 27th 2018

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

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

 

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

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

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

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

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

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

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

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

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

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

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

 

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

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Pai enviou o filho para salvar o mundo

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Clay’s Weekly Medicaid RoundUp: Week of August 20th 2018

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

 

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

 

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

  

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

  

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

  

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

 

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

 

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

 

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

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (get up early – the cool morning breezes will remind you of things forgotten) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Ojciec posłał Syna, aby zbawił świat

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Medicaid Who’s Who Interview: Thomas Kaye

Tom Kaye is an incredibly knowledgeable pharmacy executive. Check out his LinkedIn profile.

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

A: As healthcare is very broad, I have  been very fortunate to participate in many sectors. I have for the last 25 years focused on Medicaid fee for service and managed Medicaid under 1115b and 1915b waivers, commercial and Medicare part D, SNP and a few other venues. My most current assignments  has been work with several of the national top 5 insurance companies with focus on their movement into Medicaid managed care. Medicaid managed care involves states filing  of waivers with CMS for state participation as an experiential program to reduce state Medicaid costs.  New to the market  for Medicaid are the commercial power houses  insurers eager to join the ranks. My past experience has also contained hospital, ancillary infusion services, compounding, new drug development, sales and marketing for pharmaceutical with PBM services

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

A: Over 25 years

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

A: Focus Currently my ability to assist with consultative effort for changing  the velocity of pharmacy expense to plans and stakeholders. Minimally , cost avoidance  with existing tools and emerging tools are offered to lower costs  of claims / benefits.  I find that most cost reduction exist as incremental efforts, common sense issues.  The low hanging fruit as some mention, is generally picked already and there may be no gain in cost reductions utilizing this approach.

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

A: Bucket list flows over the top currently, but the top would be a train voyage stating in Canada, traversing though the great wood lands, valleys, national parks, upper north country of America and ending in southern California after 10 days.  The train has crystal glass roofs, great food and sleeping accommodations.

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

A: I enjoy wood working and engineering as a DIY “MAKER” The lack of intensity and the pleasures of wood are very rewarding and often humbling.

6. Who is your favorite historical figure and why?

A: I would choose Nikola Tesla, inventive, problem solver, and futurist.

7. What is your favorite junk food?

A: Fried pork skins, love the crunch and salt, not much flavor; might be similar to rice cakes. Pork skins go better with beer.

8. Of what accomplishment are you most proud?

A: Raising a family of three children and maintaining marriage to the same woman for 47 years. Having successfully raised the children who are married with 5 grand kids.

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

A: Redo’s are always hard, but I would take one for the multiple moves of family around the country for job opportunities.  This was disruptive for the kids.

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

1. Financially, plans are being asked as are providers to take less in compensation due to the ever-rising costs of care and supplies.  This is NOT sustainable for more than 3 years due to the drag it will place on GDP and tax burdens of the people.  We have been witnessing to the failure of the most recent design of healthcare modeling, costs and untruths. Yes the likely hood of a new program will evolve, but with this come more regulations and restrictions that take  provider time from patientsThere likely will be a deployment of new benefits which involve personal responsibility from the members.  Plans WILL move from a Risk corridor arrangement as currently set,  to an admirative services only payment process such as we have with various Medicare programs. Single payer may still be living

2. Infrastructure and telecommunications will need to be harmonized. Some relaxation as to HIPAA regulations will be needed to allow more robust communications with all stakeholders and data sharing for measurements.  Today we see a quagmire of efforts to use mobile devices, electronic communications etc.  This is a great idea ; however we have the highest costing patients (members over 50 YO) bucking the improvements and struggling with new forms of communications.  The demographic is not willing to adopt many of the new areas of communication based on lack of understanding, fear and frustration.  It will take a few years for this to subside.

Look for adoption and proliferation of IT super hubs and servers that embrace block-chain type transactional information.  The use of similar hubs and techniques such as with twitter, Facebook to improved communications to patients, providers and payment process. Legislation will be offered to embrace much more for IT compatibility across all systems. Increased transparency to cost of services will evolve though IT systems to align awareness of true prices instead of predatory pricing we see today with many oncology and transplant medications. The increased use of real time data for “Value based” care will be coming along.

3. Science never stands still. The ethical issues growing out of research is complex and often too perplexing for the human mind to cope with.  Improved understanding of the elements of humans will be pushed to the front of research. Payment for research will need to be allowed.

Look to see within the next 5 years and maybe sooner a better understanding of pathophysiology of human disease- gene sequences and informative attributes of cause and effect.  Phage deployment and advanced nanobots with  Crispr/Cas9 and newer versions of gene manipulations are moving at light speed to approved therapy.  The possible end of a PCP visit other than the patient attending a diagnostic session to take samples for a gene related medication to be made as personal medications.  The market disruption may be phenomenal as we know it today. Curative actions/steps may out pace chronic treatments with current consumption of marginal medications. The mere removal of chronic conditions such as diabetes, COPD, arthritis, cardio vascular issues would be very disruptive regarding payment, profits  and how payments are to be arranged?

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Clay’s Weekly Medicaid RoundUp: Week of August 6th 2018

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

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

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

 

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

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

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

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

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

 

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

 

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

 

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

 

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

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (cut down those browning sunflowers if you planted them; or let them dry in place and drop their seeds. According to my hunter friends, this will bring doves.) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: پدر پسر را فرستاد تا جهان را نجات دهد

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Clay’s Weekly Medicaid RoundUp: Week of July 30th 2018

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

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

 

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

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

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

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

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

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

 

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

 

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

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: پلار زوی ته واستول ترڅو نړۍ خوندي کړي

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Medicaid Who’s Who Interview: Bill Lucia

Bill Lucia has decades of experience in the healthcare system industry, specifically in the IT area. Check out his LinkedIn profile.

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

A:  My company, HMS, is a healthcare IT organization that works with multiple Medicaid stakeholders including more than 300 Medicaid payers, 45 Medicaid agencies, at-risk providers and Medicaid recipients to assure the financial integrity of Medicaid and assist our clients in understanding and managing their members.

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

A: I actually started at HMS working with safety net providers who were heavily dependent on Medicaid, 21 years ago.

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

A: My true north and passion is to help make our healthcare more efficient and effective so that everyone can lead healthier lives, not worrying about the cost of healthcare or deciding between healthcare services and putting food on the table.

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

A: I have two — first I’d like to open a shelter for abandoned and abused animals. Its at crisis proportions in our nation and we just don’t do enough. And yes this ties to health because pets can be great emotional support for the chronically ill and disabled. My second is to retire and spend half of my time in Italy living “La Dolce Vita”.

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

A: Even though I travel all the time for business, I still love to travel the world and explore other cultures. I’ve visited over 20 countries but have many more to see.

6. Who is your favorite historical figure and why?

A: Leonardo da Vinci is one of my favorite historical figures. He is best known as the artist who created the Mona Lisa and the Last Supper, but he was a true renaissance man as he was also an architect, musician, engineer, scientist and inventor. Da Vinci was ahead of his time and sketched the first parachute, helicopter, motor car and other inventions that are essesntial to modern day life. His story inspires me to be creative and innovate.

7. What is your favorite junk food?

A: Ok, two…dark chocolate with nuts (which is not junk food, it’s good for you!) and piza (it’s in my blood).

8. Of what accomplishment are you most proud?

A: Leading HMS’s growth from a small services vendor in one line of business to one of the Top 25 healthcare IT companies in th U.S. and focused on a very critical mission of making the healthcare system more effective. We’ve built a “want to” versus “have to” culture at HMS because all of our employees know the value we bring.

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

A:  Ah only one? Well personally, it would be that I wasn’t in town when my Beagle passed away. Holding an animal during it’s last breaths reminds you how fragile life can be and being abe to thank them for unconditional love.

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

A: Well, in no specific order… First, we have to aggressively attack the Opioid crisis, which disproportionately impacts the Medicaid program. Advanced analytics exist to help us do this and crack down on prescribers but also be more predictive about addiciton.

Second, we have to share more data across the healthcare system and across the entire Medicaid program. HMS recently developed a risk intelligence tool, ELLI, that does just that and enables Medicaid Managed Care plans to understand their member at enrollment, accelerating care management, avoiding costly ER visits and better engaging the member by understanding social determinants of health.

Third, we have to be careful about policy changes to Medicaid under the auspices of reform or revoking the Affordable Care Act. States need both flexibility in how to manage their programs but assurances that changes to the federal/state partnership are very carefully thought through to avoid disruption to the members, their families and providers.

 

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Clay’s Weekly Medicaid RoundUp: Week of July 23rd 2018

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

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

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

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

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

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

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

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

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. Waveny Bleckman of D.C. pled guilty this week to stealing $9.8M in Medicaid bucks using his DME company. Georgia Phillips of Brownsville, TX was ordered to pay $500k back to Medicaid after stealing taxpayer dollars (Medicaid funds) using her speech pathology clinic. Slow week for Medicaid fraud (I’m sure that these 2 cases were all the fraud that happened, so no worries taxpayers!). Waveny, you win hands down!

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

 

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

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