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REFORM- State senator suggests new health system with Medicaid block grants to local governments

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


[MM Curator Summary]: A KY legislator has introduced a block grant approach for Medicaid.



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It’s time to invent a new health care delivery system in Kentucky, and it should be driven by health-care providers, state Sen. Stephen Meredith, of Leitchfield, said in the keynote address at the Foundation for a Healthy Kentucky’s 2023 Howard L Bost Memorial Health Policy Forum, held Oct. 11 in Lexington. 

Before making this assertion, Meredith pointed to a quote attributed to Abraham Lincoln and Peter Drucker: “The best way to predict the future is to create it.” Then he said, “Let’s do that. Let’s create a new health-care delivery system.” 

The address was titled “How Do You Fix an Irretrievably Broken Health-Care System?”

Meredith spent decades as a leader in health-care administration before being elected to the Senate in 2016. When he retired as boss of Twin Lakes Regional Medical Center, now a subsidiary of Owensboro Health, it was one of the four financially strongest hospitals with under 100 beds in Kentucky. He was also CEO of the Grayson County Hospital Foundation, which employed most of the local medical practitioners and managed their practices.

Meredith, a Republican, is chair of the Senate’s Health Services Committee, co-chair of the Government Contract Review Committee, and a member of other committees, including the recently formed Family and Children Committee.

“He knows the challenges facing our health-care delivery system, because he’s seen them firsthand,” Ben Chandler, CEO president of the foundation, said in introducing him. 

Meredith opened his address by listing several known challenges with the existing health-care system, including the “astronomical” cost of care that has resulted in the average person no longer being able to afford it. 

He also called the “mass” of health-care professionals who are leaving the system “alarming” and called one of the largest insurance companies in the U.S. making a profit of $86.4 billion in the last year one of the “most damning indictments of our current health-care delivery system. “

He noted that the U.S. is spending $1.2 trillion on health care, but has some of the worst health outcomes. 

“The problem is, we know what the issues are; we don’t act on the issues,” Meredith said. 

He went on to point out that the state’s move to a managed-care program for Medicaid has been in place since 2012, “and we have not improved the health of our population.” Further, he said the state Medicaid budget was $10 billion to serve 1.3 million people, and that is as large as it should ever be. 

“In inventing a new health-care delivery system in the future, we all have to agree and acknowledge,  there’s enough money already in the health-care delivery system to take care of every man, woman and child in this country if we spend it the right way,” he said.  

Further, he said, “If we’re truly improving the health of the population and we are getting people back to gainful employment, we should have enough money to take care of everyone.” 

To do this, he said we must have a clear mission and vision for how to fix the system. 

“If we’re all united in this, it’s quite simple,” he said. “We’re here to cure the sick, to help relieve pain and suffering, to give comfort to the dying and improve the quality of life for the people we serve. If we’re all united in that, doesn’t that move us in one direction.

“And one thing I haven’t mentioned is, it doesn’t say anywhere in there to make a profit. Now, I’m a capitalist to the nth degree, and I believe in making a profit. But it’s when you bring value to the system. You increase efficiencies, and you do it a better way. And we’re not doing that.” 

He said changes should be made on the local level by moving to a Medicaid block grant program, which would allow local governments to determine how Medicaid dollars are spent, with an incentive to save money for other local purposes.

“If you improve the health of population, whatever savings you achieve, you get to keep to improve your community,” he said. “If you want to invest in your school system, you want to invest in the infrastructure, you want to invest in broadband, it’s yours to keep.” 

Meredith said the main reason we don’t do such things is fear: “People don’t like risk. Fear keeps us from doing what we need to do.”

Melissa Patrick

Author at Kentucky Health News

Melissa Patrick is a reporter for Kentucky Health News, an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Media at the University of Kentucky, with support from the Foundation for a Healthy Kentucky. She has received several competitive fellowships, including the 2016-17 Nursing and Health Care Workforce Media Fellow of the Center for Health, Media & Policy, which allowed her to focus on and write about nursing workforce issues in Kentucky; and the year-long Association of Health Care Journalists 2017-18 Regional Health Journalism Program fellowship. She is a former registered nurse and holds degrees in journalism and community leadership and development from UK.

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REFORM (CA)- Health Care ‘Game-Changer’? Feds Boost Care for Homeless Americans

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


[MM Curator Summary]: CMS approved new billing codes for “street medicine” for states wanting to deliver more care to homeless Medicaid members.



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Nurse Anna Cummings prepares an injection while Keri Weinstock, a psychiatric nurse practitioner, speaks with patient Linda Wood, who is homeless. Earlier this month, the federal government began allowing insurers to pay for care delivered outside hospitals and clinics, expanding funding for street medicine teams that treat homeless patients. (Angela Hart/KFF Health News)

The Biden administration is making it easier for doctors and nurses to treat homeless people wherever they find them, from creekside encampments to freeway underpasses, marking a fundamental shift in how — and where — health care is delivered.

Starting Oct. 1, the Centers for Medicare & Medicaid Services began allowing public and private insurers to pay “street medicine” providers for medical services they deliver anyplace homeless people might be staying.

Previously, these providers weren’t getting paid by most Medicaid programs, which serve low-income people, because the services weren’t delivered in traditional medical facilities, such as hospitals and clinics.

The change comes in response to the swelling number of homeless people across the country, and the skyrocketing number of people who need intensive addiction and mental health treatment — in addition to medical care for wounds, pregnancy, and chronic diseases like diabetes.

“It’s a game-changer. Before, this was really all done on a volunteer basis,” said Valerie Arkoosh, secretary of Pennsylvania’s Department of Human Services, which spearheaded a similar state-based billing change in July. “We are so excited. Instead of a doctor’s office, routine medical treatments and preventive care can now be done wherever unhoused people are.”

California led the nation when its state Medicaid director in late 2021 approved a new statewide billing mechanism for treating homeless people in the field, whether outdoors or indoors in a shelter or hotel. “Street medicine providers are our trusted partners on the ground, so their services should be paid for,” Jacey Cooper told California Healthline.

Hawaii and Pennsylvania followed. And while street medicine teams already operate in cities like Boston and Fort Worth, Texas, the new government reimbursement rule will allow more health care providers and states to provide the services.

“It’s a bombshell,” said Dave Lettrich, executive director of the Pittsburgh-based nonprofit Bridge to the Mountains, which provides outreach services to street medicine teams in Pennsylvania. “Before, you could provide extensive primary care and even some specialty care under a bridge, but you couldn’t bill for it.”

Under the new rule, doctors, nurses, and other providers can get reimbursed to care for patients in a “non-permanent location on the street or found environment,” making it the first time the federal government has recognized the streets as a legitimate place to provide health care. This will primarily affect low-income, disabled, and older people on Medicaid and Medicare.

“The Biden-Harris Administration has been focused on expanding access to health care across the country,” said CMS spokesperson Sara Lonardo, explaining that federal officials created a new reimbursement code at the request of street medicine providers who weren’t consistently getting reimbursed.

The White House unveiled an ambitious strategy earlier this year to reduce homelessness in America 25% by 2025, in part by plowing health care money into better care for those living on the streets.

Legislation pending in Congress would further expand reimbursement for street medicine, taking aim at the mental health and addiction crisis on the streets. The bipartisan bill, introduced earlier this year, has not yet had a committee hearing.


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Nearly 600,000 people are homeless in America, based on federal estimates from 2022, and on average they die younger than those who have stable housing. The life expectancy for homeless people is 48, compared with the overall life expectancy of 76 years in the U.S.

More than 150 street medicine programs operate across the country, according to street medicine experts. At least 50 are in California, up from 25 in 2022, said Brett Feldman, director of street medicine at the University of Southern California’s Keck School of Medicine.

Feldman spearheaded the state and national efforts to help street medicine providers get paid, alongside the Street Medicine Institute. They submitted a formal request to the Biden administration in January 2022 to ask for a new street medicine billing code.

In the letter, they argued that street medicine saves lives — and money.

“This is done via walking rounds with backpacks, usually working out of a pick-up truck or car, but is also done via horseback, kayak, or any other means to reach hard-to-reach people,” they wrote. “The balance of power is shifted to the patient, with them as the lead of their medical team.”

Street medicine experts argue that by dramatically expanding primary and specialty care on the streets, they can interrupt the cycle of homelessness and reduce costly ambulance rides, hospitalizations, and repeated trips to the emergency room. Street medicine could help California save 300,000 ER trips annually, Feldman projected, based on Medicaid data. Some street medicine teams are even placing people into permanent housing.

Arkoosh said there’s already interest bubbling up across Pennsylvania to expand street medicine because of the federal change. In Hawaii, teams are plotting to go into remote encampments, some in rainforests, to expand primary and behavioral health care.

“We’re seeing a lot of substance abuse and mental health issues and a lot of chronic diseases like HIV,” said Heather Lusk, executive director of the Hawai’i Health & Harm Reduction Center, which provides street medicine services. “We’re hoping this can help people transition from the streets into permanent housing.”

But the federal change, undertaken quietly by the Biden administration, needs a major public messaging campaign to get other states on board and to entice more providers to participate, said Jim Withers, a longtime street medicine provider in Pittsburgh who founded the Street Medicine Institute.

“This is just the beginning, and it’s a wake-up call because so many people are left out of health care,” he said.

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REFORM (VT)- Vermont officials seek Medicaid benefits for incarcerated people, but federal approval could be a long time coming

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


[MM Curator Summary]: VT’s submission of its “Global Commitment to Health” waiver adds it to the list of 14 states trying to get federal funding to turn Medicaid on before inmates re-enter society.



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A hospital bed in the infirmary unit of Southern State Correctional Facility in December 2016. File photo by Phoebe Sheehan/VTDigger

Incarcerated people have long been ineligible for Medicaid. When the federally funded health care program began in 1965, it expressly excluded “inmate(s) of a public institution” from coverage.

In Vermont and other states, officials are now embarking on a potentially arduous, yearslong process to change that — by seeking a waiver from the federal government that would allow Medicaid coverage to kick in for people in their final 90 days of incarceration. 

Prison officials and reform advocates alike say the Medicaid exclusion sometimes leads to a gap in health care coverage when people are released from prison — a vulnerable period during which they are anywhere from 10 to more than 100 times more likely than their peers to die of a drug overdose. 

“We’re very much living today with the policy decision made in the mid-1960s,” said Isaac Dayno, policy director for Vermont’s Department of Corrections. “It’s an issue that really doesn’t get enough attention.”

There’s also a potentially sizable financial benefit for the state. Vermont currently pays about $33 million per year to a private prison health contractor, Wellpath. According to 2015 data, the most recent year for which national comparisons exist, Vermont spent the second most per capita on prison health care, a Pew study found. 

Allowing Medicaid to cover incarcerated people’s medical expenses would transfer some of the financial burden of prison health care to the federal government, which, according to Dayno, could be a “paradigmatic shift.”

‘Our system is just really clunky’

While states are barred, with few exceptions, from billing Medicaid for prison health care costs, they have the option of suspending, rather than terminating, a person’s Medicaid eligibility when they enter prison. 

In theory, suspension eliminates a mountain of paperwork for people exiting prison by allowing them to access Medicaid coverage with the push of a button.

Vermont, however, lacks the IT infrastructure needed to simply suspend Medicaid eligibility.

And in practice, how — or whether — someone loses eligibility in the state is haphazard. 

More than 30% of Vermont’s prison population are people who have been detained as their cases move through the courts, rather than convicted and sentenced, state data shows. Those individuals can have their Medicaid benefits terminated even if they enter the prison system for a short time and are quickly released while awaiting trial. 

Termination may occur when a person or their family member reports they are incarcerated or when a regular check of Medicaid eligibility determines that a person is incarcerated. The corrections department, according to its health team, does not notify the Department of Vermont Health Access — the state agency responsible for Medicaid enrollment —  to “turn off” a person’s Medicaid.

When an incarcerated person approaches their release date, the Department of Corrections contacts the Department of Vermont Health Access to prepare for Medicaid enrollment, officials said.

But with unpredictable release dates, a decades-old computer system and the inevitable mistakes of a human-powered bureaucracy, eligible people sometimes exit incarceration without being enrolled in Medicaid. 

“We are not blind to a lot of the issues people face as they exit incarceration,” Dayno said. He said the process is “more seamless” in states that suspend, rather than terminate, enrollment. 

Ashley Berliner, who leads Vermont’s Medicaid policy development within the Agency of Human Services, said the state works hard to ensure people exiting state custody have coverage, using an expedited enrollment process once someone is scheduled for release.

“Our system is just really clunky,” she said, adding that enrollment is a “pretty manual process.”

Berliner called eligibility suspension the “gold standard” but said Vermont’s system “is just not capable of that functionality.”

The state is in the process of working to procure a new system. It has hired a technical advisory group and plans to release a request for proposals “for federal partner review” before the end of the year. 

‘Historically very little help’

Tim Burgess, who was previously incarcerated in Vermont and now leads the state’s chapter of Citizens United for the Rehabilitation of Errants, said he’s seen many people eligible for Medicaid leave prison without being enrolled.

“There has been historically very little help for people to transition out of the system so they do have medical coverage,” he said.

Because incarcerated people receive health care in prison, they often wrongly expect a continuity of coverage upon release, Burgess said. 

Without health coverage, recently released people may accumulate medical debt or be unable to access care, including medically assisted opioid treatment, he said, adding that Medicaid can act as a safety net and even prevent recidivism.

Burgess said he supports the variety of efforts underway to enroll incarcerated people in Medicaid, whether that means allowing coverage in the months leading up to release or ensuring reenrollment when a person returns to the community.

Will Hunter, a Windsor County advocate who rents apartments to recently incarcerated people, said their experiences with Medicaid have varied widely. 

“It does not happen automatically that the (corrections) caseworker gets a (Medicaid) application in before the person walks out the door,” he said.

Sometimes people he works with have left prison with Medicaid, Hunter said. In one instance, a former tenant on Medicaid who became incarcerated continued to have prescriptions sent to one of Hunter’s properties even while in custody. 

For people who are released without health care coverage, Hunter said he’s had good luck getting people enrolled in Medicaid over the phone, a process that can take as little as 10 to 20 minutes. That contrasts his experience with mailed applications, which he said have sometimes disappeared into a bureaucratic “black hole.”

As for Vermont’s IT struggles, Hunter felt the state shouldn’t so quickly explain away its own dysfunction.

“There’s an old saying,” he said. “A poor workman blames his tools.”

‘Back to the drawing board’  

Corrections departments nationwide support efforts to bring Medicaid into the prison system, according to Dayno — at least in part because of the potential for financial savings.

And in Congress, a bipartisan group of federal lawmakers, including U.S. Sen. Peter Welch, D-Vt., and U.S. Rep. Becca Balint, D-Vt., have thrown their support behind legislation known as the Reentry Act, which proposes restarting Medicaid benefits 30 days prior to release for people who are otherwise eligible. This would help create “uninterrupted and comprehensive coverage” upon release, according to a white paper on the bill. 

Welch called the Reentry Act a common sense way to strengthen communities, particularly amid the rise of overdose deaths

“This bill is designed to limit gaps in health care coverage for eligible people about to reenter society and has broad, bipartisan support,” he said in a statement. 

Introduced in both the House and Senate this year, the bill currently sits in committee. Rather than wait for Congress to act, some states are pursuing a different route to ensure people leave prison with health insurance. 

The federal government allows states to pursue experimental and innovative projects that would not typically be covered by Medicaid through a waiver process. Vermont’s approved waiver is the 279-page “Global Commitment to Health.”

In January, California became the first state to receive federal approval to use its waiver to cover some health expenses for incarcerated people up to 90 days prior to their scheduled release. 

Vermont is among 14 states currently seeking similar approval, according to the Kaiser Family Foundation. 

According to Berliner, the Centers for Medicare and Medicaid Services — the federal organization that administers both programs — wanted to first negotiate California’s waiver before turning to the other states seeking similar coverage of incarcerated individuals. 

Based on the Centers for Medicare and Medicaid Services’ approval of California’s waiver, Vermont officials realized “we would have to come back to the drawing board and really do some planning and design work before we went to have conversations with CMS,” Berliner said.

Vermont could receive waiver approval in 2025, according to Berliner. The state has its work cut out in the meantime, such as updating its IT system to accommodate some of the federal requirements placed on California and conforming its proposal to the strictures the Centers for Medicare and Medicaid Services have already approved elsewhere.

“Right now is a really interesting time in the Medicaid space,” Berliner said. “This is the first time that states are really able to start thinking about how Medicaid can be leveraged inside the walls of a correctional facility.”

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EXPANSION- A gradual rise, not a flood, from Medicaid expansion

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[MM Curator Summary]: SD Medicaid expansion uptake is going slowly, but officials don’t want to reduce the budget just yet.



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PIERRE, S.D. (KELO) — People didn’t immediately rush to apply for services when eligibility for South Dakota’s Medicaid program expanded July 1, but the numbers of adults enrolling in the months since then have gradually gone up, according to the leader of the state Department of Social Services that oversees it.

Are SD children well? Report reveals status

Cabinet Secretary Matt Althoff told the state Board of Social Services on Tuesday that the program was funded for this first year to handle up to as many as 57,000 new adult enrollees, as eligibility expanded from 100% to 138% of the federal poverty level. For a one-person household, the maximum income to qualify is currently $1,677 a month.

So far, applications have flowed steadily into DSS offices but there’s been no flood. Data for June showed 43,953 adults and 79,590 children eligible, as COVID-19 eligibility wrapped up. Come July and voter-approved expanded eligibility, the numbers rose for adults to 44,965, while the children fell back to 75,760. The pattern continued in August, with 46,187 adults and 74,546 children; and again for September, with 47,445 and 73,436.

“I’m really grateful they didn’t all show up on July first,” Althoff said, referring to the 57,000. “We’re far short of that.” He estimated the expanded-eligibility group would reach 11,000 to 12,000 for the first year at the current pace. “But,” he added, “steadily increasing every week.”

Althoff said he spoke about the situation Tuesday morning with the state Bureau of Finance and Management and said other states that went through eligibility expansion have suggested South Dakota wait on downsizing any projections, because they eventually reached the estimates in their states.

“It is way, way, way too early to abandon ship on our 57,000,” he said.

The department eased its way in, delaying acceptance of claims for professional medical services by a month and claims for hospital services by about two months. The department’s deputy secretary, Brenda Tidball-Zeltinger, said the most immediate claims were for pharmacy services. She noted that pharmacy and dental services were the first to receive reimbursements.

“Now we’re starting to see some of those clinical visits,” she said, and hospital services will start to show up soon.

One thing Althoff described as “uncanny” was how many of South Dakota’s expansion enrollees filed an immediate claim.

They appear to be enrolling when they need medical care,” he said.

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FRAUD, EXPANSION (NC)- Scams reported ahead of N.C. Medicaid expansion

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[MM Curator Summary]: Fraudsters are already exploiting the upcoming expansion of Medicaid in N.C. by communicating to existing and potential members they need to pay money to maintain Medicaid eligibility.


Clipped from:–medicaid–scams–healthcare–north-carolina-medicaid-expansion

North Carolina’s new state budget will expand Medicaid, making 600,000 additional people eligible for coverage.

What You Need To Know

  • The Better Business Bureau says it has received reports of scammers soliciting people who may qualify for Medicaid under North Carolina’s expansion


  • The BBB says it’s an attempt to steal identities and money


  • Scammers are also scaring people into believing they’ll lose Medicare benefits

The Better Business Bureau says it has gotten reports about scammers posing as government officials going after residents’ personal information ahead of Medicaid officially expanding on Dec. 1.

BBB president and CEO Tom Bartholomy says people who think they may be eligible for the federal program can be targets for scammers. They’re using emails, texts and social media to get through to potential victims.

“Anybody who’s not been in Medicaid before is going to go, ‘OK, maybe this is how I get going on this,'” he said. “But it’s really not the case. This is just a scammer that’s posing as state-sanctioned Medicaid expansion and they’re really just there to steal your money and steal your identity.”

Even if Medicaid isn’t on your radar, Bartholomy says con artists have other ways to get to you.

“Their other angle now is that with Medicare, open enrollment is starting on Oct. 15, and so they’re reaching out to people who are Medicare age,” he said.

He says the impostors are threatening to take away benefits unless you “take action” right away.

He recommends going directly to the government’s websites to learn more.

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FRAUD (AK)- Alaska Medicaid fraud investigation leads to indictment for Kenai doctor and staff

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[MM Curator Summary]: 23 people in AK conspired to steal Medicaid dollars using fraudulent bills to the state and MCOs.



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The exterior of the Nesbett Courthouse in downtown Anchorage on August 31, 2022. (Valerie Kern/ Alaska Public Media)

A Kenai doctor and his clinics’ managers face nearly two dozen felony charges in an alleged Medicaid fraud case after a grand jury indicted them Wednesday.

Prosecutors say Dr. Ray Lynn Carlson, owner of MediCenter clinics on the Kenai Peninsula, fraudulently billed Alaska Medicaid and two insurance companies – Aetna and Premera – from 2014 to 2019.

Also named in the indictment are Scott Carlson, Charise Carlson and Joseph Hurley, as well as a corporation in Ray Carlson’s name, under which he owned two MediCenter clinics, one in Kenai and one in Nikiski.

Each of the defendants faces 23 criminal counts, including fraud, theft and fraudulent insurance acts.

There is limited information about the alleged fraud in the grand jury’s indictment, but it indicates the defendants overbilled Medicaid and the insurance companies and, in at least some instances, submitted false medical billing codes.

Carlson’s MediCenter clinics appear to have closed sometime after the Alaska Medicaid Fraud Control Unit’s investigation began. According to a Peninsula Clarion newspaper story from 2019, investigators had searched MediCenter’s offices that July.

Phone numbers at both clinics are now disconnected. None of the defendants had attorneys listed in court records as of Friday.

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FWA (KY)- Oxygen Plus to pay $200,000 to resolve allegations of bilking Medicare, Medicaid

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[MM Curator Summary]: 2 whistleblowers tipped off investigators about the company’s bogus billing for vent machines.



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STANVILLE, Ky. — A Floyd County company has agreed to pay $200,000 to resolve allegations that it defrauded the government by billing for unnecessary medical equipment.

The U.S. Attorney’s Office for the Eastern District of Kentucky announced the settlement on Tuesday.

Oxygen Plus, based in Stanville, rents non-invasive ventilators for patients with severe respiratory diseases to use at home. The company was accused of submitting more than 300 false claims to Medicare and Medicaid between 2017 and 2021, by continuing to bill for the rentals even after the patients were no longer using them.

The allegations were brought to light by two whistleblowers who worked at the company as a respiratory therapist and a bookkeeper. They accused the company of pressuring employees to solicit Medicare and Medicaid beneficiaries to rent the machines.

The lawsuit lists five patients who were given lifetime prescriptions for the ventilators, despite not showing symptoms to support a diagnosis of respiratory failure. One of those patients was never examined by a doctor.

For reporting the false claims to the government, the whistleblowers will split a $32,000 share of the settlement.

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FRAUD (FL)- 20 arrested, accused in $5 million Medicaid transportation scheme involving Jacksonville company

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[MM Curator Summary]: The GPS systems in their vehicles helped get the conviction.




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20 arrested, accused in $5 million Medicaid transportation scheme involving Jacksonville company

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20 arrested, accused in $5 million Medicaid transportation scheme involving Jacksonville company

JACKSONVILLE, Fla. – Florida Attorney General Ashley Moody said in a statement Thursday that 20 people have been arrested in a $5 million Medicaid scheme involving a Jacksonville transportation company.

RELATED | I-TEAM: Patients left stranded by non-emergency medical transportation provider

Many of the suspects are from Jacksonville, including Jose Hernandez Fernandez, who is the owner Sweet Transportation.

Investigators said the company, which provided non-emergency transportation for Medicaid recipients, billed Medicaid for thousands of patient trips that never happened. The trips were supposed to help patients receive medical care.

Hernandez Fernandez is accused of fraud, racketeering and money laundering.

The Medicaid transportation system has received plenty of complaints and was the subject of an I-TEAM investigation last year.

According to investigators, Jose Hernandez Fernandez started Sweet Transportation in 2019, and in 2020, when the company had just two drivers, it contracted with Modivcare, which is a vendor with the state to coordinate transportation for Medicaid patients. It was in 2022, investigators said, that Sweet Transportation reached its peak of 30 drivers.

The I-TEAM has previously reported on concerns about Modivcare and their various subcontractors arriving late for appointments or not at all.

On Thursday, News4JAX spoke again with Rene Reynolds, who said that her 84-year-old father struggled to get reliable transportation from Modivcare before his death earlier this year.

“It gives me a little bit more encouragement that there are good things that happen when somebody speaks up, me and other people speak up,” Reynolds said.

She said she’s not sure if Modivcare ever assigned Sweet Transportation to transport her father because she typically wasn’t made aware of which subcontractors were providing him rides.

According to investigators, Sweet Transportation drivers would bill for trips that never happened and inflate mileage for trips they did complete, but they were busted with help from the mandatory GPS technology installed in their vehicles.

In a separate civil lawsuit filed by the attorney general’s office, investigators said Hernandez Fernandez charged Florida Medicaid for nearly 3,000 trips as a driver in the Jacksonville area when he was actually in South Florida, Georgia, New York, Massachusetts, Colorado, Nebraska, Kansas and Puerto Rico.

“It’s refreshing to know that there is there is some justice out, there but I think it’s a drop in the bucket this fellow I think that there’s plenty more,” Reynolds said.

Hernandez Fernandez and 20 employees of Sweet Transportation are all accused of participating in the Medicaid scheme and are facing criminal charges and named in a civil racketeering lawsuit brought by the state.

According to police records, the investigation into Sweet Transportation began after United Health Care, which manages Medicaid services, complained about possible fraud.

A spokesperson for Modivcare sent the I-TEAM a statement Thursday, stating, “Modivcare has fully cooperated with the [Attorney General’s] Medicaid Fraud Control Unit (MFCU) through the entirety of this investigation.”

News4JAX tried to reach Hernandez Fernandez’s attorney but has not yet received a response.

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TECH- Waymark Secures Additional $42M to Scale Tech-Enabled, Community-Based Care for Primary Care Providers and People Enrolled in Medicaid

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[MM Curator Summary]: CVS makes another huge investment into its tech portfolio.




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New Funding Will Support Waymark’s Market Expansion and Technology Investments to Continue Improving Access and Outcomes for Medicaid Recipients


SAN FRANCISCO, October 18, 2023 ( – Waymark, the Medicaid provider enablement company, today announced $42 million in new financing to scale technology-enabled, community-based care for primary care providers and their patients enrolled in Medicaid programs. Existing investor Lux Capital led the oversubscribed round, and CVS Health Ventures, the venture capital arm of CVS Health, joins the company as a new investor. Existing investors Andreessen Horowitz (a16z) and New Enterprise Associates (NEA) also participated in the round. The investment consists of $22 million in equity capital and a $20 million line of credit, bringing Waymark’s total capital raised to date to $87 million. 

“CVS Health Ventures’ investment portfolio is comprised of innovative companies that are at the forefront of transforming care delivery. Waymark’s use of proprietary data science technologies to improve access and quality of care is doing exactly that,” said Vijay Patel, Managing Partner and co-founder, CVS Health Ventures. “We expect this investment will provide Medicaid members expanded access to coordinated and holistic health care.”

Waymark will use its new investment to continue improving healthcare access and outcomes for people enrolled in Medicaid programs. Patients receiving Medicaid benefits often experience challenges accessing care, prescriptions, and social support like housing and food. Waymark hires, trains, and deploys local teams of community health workers, pharmacists, therapists and care coordinators to work directly with primary care practices — at no cost to the practice — and address gaps in care for their patients enrolled in Medicaid. The company’s local teams are supported by Waymark Signal™, a proprietary machine learning technology that has shown industry-leading performance in identifying “rising risk” populations, or patients at risk of avoidable emergency room (ER) and hospital utilization, and helps to direct Waymark teams to the best evidence-based intervention to meet patient goals. The technology is integrated into a care management software built by Waymark specifically for community-based teams, and incorporates data from multiple sources (e.g., local ERs, primary care practices, social services databases, and health plan data) to engage patients who are traditionally hard to reach. 

“Medicaid programs have historically been overlooked and under-innovated, but Waymark’s groundbreaking partnerships demonstrate the positive impact technology-enabled services can have for communities who need it most,” said Deena Shakir, General Partner at Lux Capital. “By aligning business incentives with patient outcomes, Waymark continues to build a uniquely effective approach to advance population health. There is no better team or technology out there to take this challenge on, and we are thrilled to deepen our partnership with the entire Waymark team.”

Waymark is currently supporting approximately 50,000 people enrolled in Medicaid across both Washington state and Virginia. Since launching in January 2023, the company has secured partnerships with several large health systems, a federally qualified health center (FQHC), and independent practices across both markets. Through its evidence-based care pathways, Waymark has shown promising early improvements in quality scores and clinical outcomes — including reduced non-emergent emergency department (ED) visits and hospitalizations.

Providence, one of the largest health systems in the country, is working with Waymark to improve access to care for patients receiving Medicaid. “At Providence, we’re committed to addressing inequities in the communities we care for,” said Dr. Scott Anders, CMO, Value Based Care, Providence Clinical Network, Providence Health & Services. “Waymark provides a disciplined Medicaid population health management approach that improves access to high-value care. Waymark’s use of data science combined with a local, person-centered process is compelling, and we are eager to see how they proactively help patients access the care they need.” 

At community clinics like Country Doctor Community Health Center (CDCHC), a Seattle-based federally qualified health center (FQHC) with roots in the civil rights movement, Waymark is helping to increase provider capacity and deliver whole-person care to patients. “We chose to partner with Waymark because their local, community-based, multidisciplinary care model aligns not only with the evidence of what works in Medicaid, but also our own mission and values,” said Matthew Logalbo, MD and Medical Director, CDCHC. “We have worked hard to develop services tailored to the needs of our patients (e.g., our low-barrier addiction treatment clinic, peer support specialists, re-entry CHWs, and healthcare for the homeless services), but we can’t meet the level of demand that exists alone. Waymark provides us with more capacity outside the clinic setting to engage and support patients, bring them into care, and connect them to our programs and other resources in the community that can address patients’ social determinants of health.”

Waymark enters into risk-based contracts with Medicaid MCOs to deliver community-based care for their rising risk populations and transition primary care practices to value-based arrangements. By building a new community health workforce to support primary care providers (PCPs) — paid for through value-based arrangements with MCOs — Waymark seeks to increase the capacity of its healthcare delivery system and align payment incentives to enable whole-person care.

“We created Waymark because the evidence of what works to improve Medicaid outcomes exists, but the operational capacity, technology and funding is insufficient to scale to the level of need that exists in communities across the country,” said Dr. Rajaie Batniji, co-founder and CEO of Waymark. “This new financing will allow us to continue hiring and training a new community health workforce, expand PCP capacity, and ultimately deliver on our charter to improve access and quality of care for people receiving Medicaid.” 

Source: Waymark

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TECH – Gainwell Enables Breakthrough Southern Methodist University Research on Hospital Readmissions for Medicaid Diabetes Patients

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


[MM Curator Summary]: Gainwell is re-selling state Medicaid data to researchers.



Clipped from:

New model holds key to accurately predicting 30-day patient readmission

IRVING, Texas, Oct. 17, 2023 (GLOBE NEWSWIRE) — Hospital readmission for diabetes patients is an enormous health risk and an expensive problem for the U.S. healthcare system. The question is how do we address it?

Gainwell Technologies (Gainwell), a leading innovator in healthcare technology solutions, partnered with its state Medicaid clients and SMU (Southern Methodist University) to develop an answer.

Diabetes affects roughly 13 percent of the U.S. population. These patients have elevated rates of hospital admission and all-cause mortality. They are also twice as likely to be readmitted within 30 days of discharge as similar patients without diabetes. The estimated cost of hospital readmissions is $20 billion to $25 billion annually.

While predictive hospital readmission models for diabetes exist for Medicare, they do not for Medicaid, which is the single largest source of health insurance in the U.S. This fact helped motivate this research.

SMU determined the first step was to develop a model to predict which Medicaid patients admitted to a hospital for any reason are most likely to be readmitted within 30 days. To develop a predictive model, Gainwell enabled SMU’s research by providing an advanced research platform and de-identified Medicaid claims from its clients in seven states.

SMU used 69,640 claims for the research that focused exclusively on patients who were diabetic, admitted to the hospital for any reason and discharged either to their homes or a non-hospice facility.

Using claims data only, SMU concluded Medicaid patients with diabetes were much more likely to be readmitted to hospitals within 30 days of their release than Medicaid patients without diabetes.

This important research was published in The
American Journal of Managed Care
(AJMC), a respected peer-reviewed medical journal.

Some of the most significant findings from the research were:

  • Researchers derived and validated a Medicaid claims-only statistical model to predict 30-day readmission for hospitalized Medicaid patients with diabetes.
  • The model’s accuracy is similar to that of other models that are based on more granular clinical and demographic data. It identifies populations by risk and suggests targets for interventions to improve outcomes.
  • The model will be of use to insurers, policymakers and health systems as they seek to categorize patients by risk to improve health outcomes and contain readmission costs in Medicaid programs.

The research will enable payers and health systems to use a patient’s age, gender and admissions history to predict the likelihood of a readmission.

“This research provides important guidance to clinicians,” said Daniel Heitjan, Ph.D., professor and chair of Statistics and Data Science at SMU. “Our new predictive model is accurate and much simpler to process. That’s a significant advantage when predicting the likelihood of readmission.”

A cost driver in healthcareThirty-day readmissions are widely recognized as a driver of increased healthcare costs. And it is to the benefit of hospitals and health plans to address it.

“These results are important to ensure patients get the care they need for this pervasive and deadly disease. This predictive model will help providers and payers identify Medicaid patients with a higher risk of readmissions. It also enables them to proactively focus on care transitions to improve outcomes and decrease costs,” said Gainwell Chief Medical Officer Dr. Gary Call.

“By identifying high-risk diabetics, clinicians will be better equipped to focus on patients during and after hospitalizations to improve treatment adherence and avoid readmissions. These models can also track high-risk population outcomes, develop care management programs and monitor the effectiveness of existing ones,” Dr. Call said.

He added the research would not have been possible without the foresight of Gainwell’s clients who enabled the company to share the de-identified Medicaid claims for this vital research.

Cooperative researchThis research is one in a series of studies Gainwell has enabled for top universities on issues ranging from hospital readmissions to opioid addiction to the impact of the social determinants of health.

Gainwell facilitated the research data environment for SMU under the umbrella of Australia’s Digital Health CRC (Cooperative Research Centre) to sponsor this study. The DHCRC connects government, academic and industry partners to harness digital technology to address many of the world’s most challenging healthcare issues.

About Gainwell TechnologiesGainwell Technologies is the leading provider of digital and cloud-enabled solutions vital to the administration and operations of health and human services programs. With more than 50 years of proven experience, Gainwell has a reputation for service excellence and unparalleled industry expertise. We offer clients scalable and flexible solutions for their most complex challenges. These capabilities make us a trusted partner for organizations seeking reliability, innovation, and transformational outcomes. Learn more at

About SMUSMU is the nationally ranked global research university in the dynamic city of Dallas. SMU’s alumni, faculty and over 12,000 students in eight degree-granting schools demonstrate an entrepreneurial spirit as they lead change in their professions, communities and the world.

CONTACT: Elizabeth Bonet, Gainwell Technologies972-556-5082


Source: Gainwell Technologies LLC