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Massachusetts Suit Over Circumcision Medicaid Payments Fails

MM Curator summary

[MM Curator Summary]: Low income families will still have access to circumcision services, much to the chagrin of far left wing anti-circumcision extremists.

 
 

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.

 
 

Several Massachusetts taxpayers lost a lawsuit to prohibit the state’s Medicaid agency from paying for neonatal male circumcisions, because they have no actionable claim under either federal or state law, a state appeals court said.

Private citizens don’t have a right to enforce a state regulation precluding MassHealth from paying for services that aren’t medically necessary, because the decision of what constitutes a medically necessary service is committed to the agency’s discretion, the Massachusetts Court of Appeals said.

The plaintiffs alleged that most circumcisions aren’t medically necessary and usually are done at the request of the parents for cultural or …

 
 

Clipped from: https://news.bloomberglaw.com/health-law-and-business/massachusetts-suit-over-circumcision-medicaid-payments-fails

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Nebraska Medicaid Announces Requests for Proposal For New Health Insurance Contracts

MM Curator summary

[MM Curator Summary]: Awards are currently expected late August.

 
 

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.

 
 

LINCOLN — The Nebraska Department of Health and Human Services (DHHS) has received bids from five health plans to provide healthcare services for its Medicaid managed care program. A request for proposals (RFP) was initially posted in April 2022, and bids were due July 1.

The five bidding companies are:

• Community Care Plan of Nebraska, Inc. d/b/a Healthy Blue

• Medica Community Health Plan

• Molina Healthcare of Nebraska, Inc.

• Nebraska Total Care, Inc.

 
 

• UnitedHealth Care of the Midlands, Inc.

Of the named bidders, Nebraska Medicaid will select two to three to provide physical health, behavioral health, pharmacy, and dental services. The chosen bidders will be contracted with DHHS for at least five years to provide most healthcare services to the members in managed care.

Nebraska Medicaid plans to announce the winning bidders in late August. From now until then, the bids will be scored based on specific and general expertise by Medicaid leaders. The State answered two rounds of bidders’ questions prior to the due date.

The bidders will be evaluated based on criteria through their proposals, which may include oral interviews, as part of the multi-stage process. The companies bring forward action plans and discuss their past learning experiences. From there, Medicaid will determine which are best suited to provide the best service to our members and providers over the next several years.

“Our goal throughout this RFP has been to improve our members’ and providers’ experience by building on previous successes and making thoughtful changes in response to stakeholder feedback,” Medicaid Director Kevin Bagley said. “That goal will be top of mind for our team as we rigorously evaluate these five proposals over the coming weeks.”

The new RFP includes several changes, integrating dental services with physical health, behavioral health, and pharmacy services; simplifying credentialing for providers; and improving electronic visit verification. After the winning bidders are chosen, Medicaid will work on implementing these changes as smoothly as possible for our members.

 
 

Clipped from: https://www.yankton.net/community/article_d1b96960-0c91-11ed-8f54-6bdccbfaa152.html

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INDIANA- Local businessman accused of medicaid fraud, counterfeiting

MM Curator summary

[MM Curator Summary]: Timothy Adkins may or may not have forged doctor’s signatures thousands of times, depending on whether or not you believe the docs whose signature are in question. He’s facing about $950,000 of fraud allegations.

 
 

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.

 
 

 
 

Timothy Dwain Adkins

HANCOCK COUNTY — A six-year investigation by officials with the Family and Social Services Administration (FSSA) concluded a local man committed medicaid fraud and counterfeiting, resulting in the misuse of thousands of state dollars.

The case is being prosecuted by officials from the Attorney General’s office. It was officially opened in Hancock County Circuit Court last week under the supervision of Judge Scott Sirk.

Timothy Dwain Adkins, 66, 300 block of Shadow Creek Pass, Greenfield, has been charged with three Level 5 felony medicaid fraud charges and one Level 6 felony charge of counterfeiting from incidents in 2017 and 2018. The most serious charge carries up to six years in prison.

According to a probable cause affidavit, there is sufficient reason to believe Adkins committed medicaid fraud when he submitted claims to Indiana Medicaid stating doctors were the rendering Health Service Provider in Psychology (HSPPs) when they were not. Additionally, officials believe Adkins committed forgery in 67 instances where the signature of a doctor was signed on patient treatment plans.

The report states FSSA contacted the Medicaid Fraud Control Units (MFCU) and reported suspected fraudulent billing of in-home psychotherapy services, Behavior Source, LLC. Behavior Source is a provider of mental health services, owned by Adkins, who holds no psychology licenses or credentials.

According to the Better Business Bureau, the business was opened in Indianapolis 2012 with Adkins named as the business manager and director of operations. Behavior Source employs HSPPs and provides billing and HSPP oversight services to businesses who provide outpatient psychotherapy, the report states.

A doctor told officials he worked for Behavior Source as an HSPP until July 23, 2017. The doctor stated he did not see any patients of Behavior Source after July of 2017, contrary to billing data showing the rendering HSPP through May 2019.

A subsequent pull of billing data indicated billing was submitted by Behavior Source with the doctor listed as the rendering HSPP through March 8, 2021. In total, 12,472 claims were submitted to Indiana Medicaid totaling $475,116 where the doctor was listed as the rendering provider despite his statement he no longer worked for Behavior Source, the report states.

In March 2020, an investigator interviewed another doctor who said she was an HSPP for Behavior Source during two different time periods: first in 2016 or 2017 for approximately three or four months, and then starting again on August 12, 2019. Officials noted there were treatment plans which had her signature on them in 2018, but the doctor could not explain how her signature could be on the documents.

In September 2021, the MFCU sent a subpoena to Behavior Source for patient records to conduct a random sample audit of 23,812 claims submitted to Indiana Medicaid by Behavior Source from Jan. 1, 2017 to Aug. 20, 2021.

The report states a review showed a 60.30% error rate — meaning the percentage of the reviewed claims and patient records did not meet the program requirements necessary for reimbursement from Indiana Medicaid — because patient treatment plans were not signed by a physician or HSPP noting the HSPP signatures were forged, or the dates of review exceeded the regulatory requirements.

The fraudulent billing for non-compliant services equates to an actual over-payment of $12,936.63 and an extrapolated value to the total claims of $947,837.03, the report states.

Adkins was interviewed by investigators in February. Adkins told officials he was not surprised by the error rate and said he shared the concern of treatment plans not having HSPP signatures, the report states.

Adkins said, depending on the date, faxes from one doctor did not always come in on a regular basis. Adkins said the ability of therapists to get documentation back to him with HSPP signatures was “spotty,” the report states.

Adkins told officials one of the doctors would not sign the vast majority of the treatment plans submitted to him by therapists because the doctor wanted more definition in specific areas of the treatment plan. Adkins said this put him into a considerable “panic” because Behavior Source had just signed contracts with additional school districts and had therapists depending on HSPP approval from Behavior Source, the report states.

Adkins said he knew it was “messed up,” the report said, but he didn’t want to stop services to over 500 kids, 40 therapists and schools who would have no services. Adkins said he set aside money to pay back Indiana Medicaid and said, “I’ll fall on the sword if need be,” the report states.

According to the report, Adkins agreed that he was not providing services at the level they were required to be provided by Medicaid, as he was not having proper HSPP oversight of mid-level providers.

When asked about one doctor’s signatures on 67 documents, from January 2017 through August 2019, Adkins told officials in the report there was never a time the doctor’s signature was on paperwork for Behavior Source when she did not work for Behavior Source.

Adkins admitted his normal procedure during the doctor’s employment was to electronically cut out a signature, paste it on the document and send the pre-signed document to the doctor.

Adkins stated he did this so he wouldn’t need to meet with doctor in person, the report states. When officials interviewed the doctor, the doctor said her process was to always sign documents in pen. When asked if the doctor had ever received pre-signed documents from Adkins for review, she emphatically denied that ever happened, the report said.

When analyzing the billing data submitted to Indiana Medicaid by Behavior Source from January 2018, to August 2019 officials say where some 4,679 claims, totaling $92,650, were submitted to Indiana Medicaid where the doctor was listed as the rendering provider despite her statement she did not work for Behavior Source during this period and did not sign or authorize any documents.

Adkins made his initial appearance in Circuit Court late Friday when he was officially arrested. No bond amount was listed, however he is not an inmate in the county jail. Adkins is slated to be back in court in late September for a pretrial conference.

 
 

Clipped from: https://www.greenfieldreporter.com/2022/07/26/local-businessman-accused-of-medicaid-fraud-counterfeiting/

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Patient-level factors influencing adherence to follow-up imaging recommendations

 
 

MM Curator summary

[MM Curator Summary]: Even after accounting for all other person-level variables, Medicaid members still don’t complete ordered imaging followups.

 
 

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.

 
 

 
 

Purpose

To determine which, if any, patient-level factors were associated with differences in completion of follow-up imaging recommendations at a tertiary academic medical center.

Methods

In this IRB-approved, retrospective cohort study, approximately one month of imaging recommendations were reviewed from 2017 at a single academic institution that contained key words recommending follow-up imaging. Age, gender, race/ethnicity, insurance, smoking history, primary language, BMI, and home address were recorded via chart extraction. Home addresses were geocoded to Census Block Groups and assigned to a quintile of neighborhood socioeconomic status. A multivariate logistic regression model was used to evaluate each predictor variable with significance set to p = 0.05.

Results

A total of 13,421 imaging reports that included additional follow-up recommendations were identified. Of the 1013 included reports that recommended follow-up, 350 recommended additional imaging and were analyzed. Three hundred eight (88.00%) had corresponding follow-up imaging present and the insurance payor was known for 266 (86.36%) patients: 146 (47.40%) had commercial insurance, 35 (11.36%) had Medicaid, and 85 (27.60%) had Medicare. Patients with Medicaid had over four times lower odds of completing follow-up imaging compared to patients with commercial insurance (OR 0.24, 95% CI 0.06–0.88, p = 0.032). Age, gender, race/ethnicity, smoking history, primary language, BMI, and neighborhood socioeconomic status were not independently associated with differences in follow-up imaging completion.

Conclusion

Patients with Medicaid had decreased odds of completing follow-up imaging recommendations compared to patients with commercial insurance.

 
 

Clipped from: https://www.clinicalimaging.org/article/S0899-7071(22)00184-X/fulltext

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GDIT Wins $65 Million Medicare and Medicaid Cloud and Data Integration Contract

MM Curator summary

[MM Curator Summary]: The award will be to implement a data warehouse that includes claims and member data for Medicare and Medicaid programs.

 
 

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.

 
 

 
 

Government Technology and Services Coalition member and mentor partner General Dynamics Information Technology (GDIT), a business unit of General Dynamics, has been awarded a new $65 million contract by the Centers for Medicare & Medicaid Services (CMS) Enterprise Architecture Data Group to support its Integrated Data Repository (IDR). The five-year contract has a one-year base period, three one-year and one eight-month option periods, and one four-month transition period.

CMS maintains the largest volume of healthcare data files in the world. The IDR is a high-volume data warehouse integrating claims, beneficiary and provider data sources to support various Medicare and Medicaid programs. Access to this robust integrated data supports analytics across CMS, including insights into medical trends, healthcare costs, and fraud, waste and abuse.

Under this contract, GDIT will provide agile transformation and development, security and operations services in support of on-premise and cloud systems. GDIT will support the migration to the cloud and provide operations and maintenance services on both systems.

“CMS has made incredible progress as it moves its enterprise systems to the cloud,” said Kamal Narang, vice president and general manager for GDIT’s Federal Health sector. “This is another step in improving the agency’s data accessibility and analysis capabilities. As one of the largest providers of cloud services to CMS, we are proud to continue providing our cloud expertise to support their modernization journey.”

The contract continues GDIT’s 40-year partnership with CMS. In September 2020, CMS selected GDIT to evolve one of the largest public clouds in the federal government. Under that task order, GDIT is supporting the agency to help optimize its cloud technology investments and financial operations as it implements a mature multi-cloud environment designed to deliver critical healthcare services to tens of millions of Americans through hosted sites, Medicare.gov and Healthcare.gov.

Read more at GDIT

 
 

Clipped from: https://www.hstoday.us/industry/industry-news/gdit-wins-65-million-medicare-and-medicaid-cloud-and-data-integration-contract/

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New York Office of Medicaid Inspector General Proposes Regulations on Medicaid Provider Compliance Programs

MM Curator summary

[MM Curator Summary]: If the OIG has its way, MCOs will be added to the list of groups who have to prove they are dealing with fraud, waste and abuse.

 
 

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.

 
 

The New York State Office of Medicaid Inspector General (OMIG) published proposed regulations in the July 13, 2022 issue of the New York State Register.  The proposed regulations would repeal the current Part 521 – Provider Compliance Programs of Title 18 of the New York Codes, Rules and Regulations (NYCRR) in its entirety and establish new requirements for providers to detect and prevent fraud, waste and abuse in the Medicaid Program under a new Part 521: Fraud, Waste, and Abuse Prevention (Part 521). Part 521 would implement provisions of the New York State Fiscal Year 2020-2021 Enacted Budget and recommendations from the Department of Health’s Medicaid Redesign Team II. 

If enacted, the proposed rules would implement changes related to Medicaid provider compliance programs, Medicaid managed care organization (MCO) fraud, waste, and abuse prevention, and Medicaid providers’ “obligation to report, return, and explain Medicaid overpayments through OMIG’s Self-Disclosure Program.”  We have highlighted below certain provisions from the first of Part 521’s three subparts, Subpart 521-1, that are relevant to New York Medicaid providers as they structure and update their compliance programs.

Scope and Applicability of Program – Section 521-1.1

These proposed regulations require certain “Required Providers” (defined below) participating in the Medical Assistance program (Medicaid) to adopt a compliance plan to detect and prevent fraud, waste, and abuse in the Medicaid program. The following are deemed Required Providers and are obligated to comply with this proposed regulation:

  • hospitals, nursing homes, residential care facilities, and home care service agencies;
  • family care homes and residential treatment facilities for children and youth;
  • any managed care provider or managed long term care plan; and
  • any other person for whom the Medicaid program is or is reasonably expected to be a “substantial portion of their business operations.”  “Substantial portion of their business operations” includes persons who have claimed or received at least $1,000,000 a year from the Medicaid program. The current statutory definition sets $500,000 as the threshold.

In the current regulations, managed care providers and managed long term plans are not included in the scope of the Required Provider definition. 

Duties of Required Providers – Section 521-1.3(a)

To receive payment through the Medicaid program, Required Providers must maintain a compliance program. The regulations define an “effective compliance program” as a program that is:

  • well-integrated into the company’s operations and supported by the highest levels of the organization;
  • promotes adherence to the Required Provider’s legal and ethical obligations;
  • and is designed and implemented to prevent, detect, and correct non-compliance with Medicaid program requirements, such as fraud, waste, and abuse.

The provider must ensure that contracts with contractors, agents, subcontractors, and independent contractors are subject to their compliance program, and if such individuals meet the definition of an Affected Individual, the contracts must include termination provisions for failure to adhere to the Required Provider’s compliance program requirements. The proposed regulations define Affected Individuals as “persons who are affected by the Required Provider’s risk areas including the Required Provider’s employees, the chief executive and other senior administrators, managers, contractors, agents, subcontractors, independent contractors, and governing body and corporate officers.”

Risk Areas for Providers and Medicaid MCOs – Section 521-1.3(d)

The proposed regulations indicate there are ten risk areas, defined as areas of operation affected by the compliance program, that the compliance program must apply to:

  • billings;
  • payments;
  • ordered services;
  • medical necessity;
  • quality of care;
  • governance;
  • mandatory reporting;
  • credentialing;
  • contractor, subcontractor, agent, or independent contract oversight; and
  • other risk areas that are or should reasonably be identified by the provider through “organizational experience.” 

The regulations define “organizational experience” to include four components, which include the Required Provider’s knowledge, skill, practice, and understanding in operating a compliance program; identification of issues or risk areas; experience, knowledge, skill, practice and understanding of its participation in the Medicaid program; and awareness of issues it should reasonably become aware of for its services.

In the current regulations, “ordered services” and “contractor, subcontractor, agent, or independent contractor oversight” are not risk areas that were are required to be addressed in a Required Provider’s compliance program. The proposed regulations also add ten additional risk areas for Medicaid MCOs, which must also be addressed in their compliance programs.  These additional areas of risk include:

  • Compliance with Medicaid MCO’s contract terms;
  • Cost reporting;
  • Submission of encounter data;
  • Network adequacy and contracting;
  • Provider and subcontractor oversight;
  • Underutilization;
  • Marketing;
  • Provision of medically necessary services;
  • Payments and claims processing; and
  • Statistically valid services verification.

Certification – Section 521-1.3(f)

Required Providers must submit an annual certification to the Department of Social Services that it maintains a compliance program.  The Required Provider must also submit a copy of such certification to each Medicaid MCO with which the Required Provider has a provider agreement.

Written Policies of Compliance Program – Section 521-1.4(a)

Required Providers are required to have written policies, procedures, and standards of conduct that govern the compliance program. These policies, procedures, and standards of conduct must cover several topics, including providing guidance on dealing with compliance issues, descriptions of how compliance issues are investigated and resolved, and include a policy of non-intimidation and non-retaliation for good faith participation in the compliance program. The policies and procedures must be reviewed at least annually.

Compliance Officer and Compliance Committee – Section 521-1.4(b)-(c)

In the current regulations, a Required Provider was responsible for designating one employee that is responsible for the compliance program’s operation.  Now, under the proposed regulations, Required Providers must designate a compliance officer who will oversee, monitor, and review the compliance program, implement compliance work plans, and investigate matters related to the compliance program. The compliance officer will also coordinate with a designated compliance committee. The compliance committee will be responsible for, among other things, collaborating with the compliance officer on written policies and procedures, ensuring that the compliance officer is allotted sufficient resources to perform their job, and enacting required modifications to the compliance program.

Compliance Training and Education – Section 521-1.4(d) 

Required Providers must maintain a compliance training and education program for the compliance officer and all Affected Individuals.  This training must be completed at least annually. The training and education must include, at a minimum, a discussion of the following:

  • risk areas and organizational experience of the Required Provider;
  • written policies, procedures, and standards of conduct related to compliance;
  • the role of the compliance officer and compliance committee;
  • the obligation of Affected Individuals to report compliance concerns, the procedures for reporting concerns, and the non-intimidation and retaliation policies of the Required Provider;
  • disciplinary standards related to the compliance program and fraud, waste, and abuse prevention;
  • corrective action plans and response to compliance issues;
  • Medicaid program requirements and the Required Provider’s category of services;
  • coding and billing requirements and best practices;
  • claim development and submission; and
  • for Medicaid MCOs only, the fraud, waste, and abuse prevention program requirements of Subpart 521-2 (which will be further discussed in a future Mintz blog post).

OMIG Compliance Program Reviews – Section 521-1.5 

OMIG may review a Required Provider’s compliance program to determine its compliance with the regulations. OMIG will notify a Required Provider of its intent to commence a review, and such notice will include the review period and procedures that will be undertaken to complete the review.  Once the review is complete, OMIG will advise the Required Provider if it satisfies the requirements of Part 521 and if any deficiencies need to be corrected.

Conclusion

If enacted, Part 521-1 will compel Medicaid providers and Medicaid MCOs to examine and, potentially, restructure their compliance programs. OMIG is accepting public comment on these proposed regulations through September 11, 2022.

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Clipped from: https://www.mintz.com/insights-center/viewpoints/2146/2022-07-26-new-york-office-medicaid-inspector-general-proposes

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Mark Farrah Associates Noted More Than One-Quarter of U.S. Population on Medicaid

MM Curator summary

[MM Curator Summary]: There was very little movement in the year over year market share race amongst the MCOs.

 
 

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.

 
 

 
 

July 18, 2022

On July 15, 2022, Health and Human Services (HHS) Secretary Xavier Becerra, once again, renewed the determination that we are in a national public health emergency (PHE) through October 13, 2022. 1 Until the PHE is lifted Medicaid redeterminations2 continue to remain on hold and Medicaid enrollment will continue to increase. Medicaid enrollment through the first quarter of 2022 (1Q22) has reached close to 86 million, up 4 million enrollees from 1Q21.

Medicaid membership − available through the National Association of Insurance Commissioners (NAIC) and California Department of Managed Health Care (CA DMHC) statutory sources; and State managed and non-managed Medicaid program reports; and aggregated in Mark Farrah Associates’ Health Coverage Portal TM now stands at 85,970,046, or 25.8% of the 332.78 million people in the U.S., as of March 2022. Using MFA’s Health Coverage Portal™ you can obtain the enrollment source breakdown as represented in the following table, as well as state specific enrollment by carrier.

 
 


 
 

The trend toward states adopting managed Medicaid programs continued between 1Q21 and 1Q22. One of the largest shifts noted during this period was in the state of North Carolina (NC), which converted to a managed Medicaid program. Approximately 1.6 million beneficiaries began receiving Medicaid services through NC Managed Care health plans starting July 1st, 2021. 

Market Share

The table below shows that the top 10 companies in March of 2022 all increased Medicaid enrollment from the same period in 2021. Centene remained the leader with a 16.5% market share, which is a decrease of 0.4% from 1Q21. Seven of the top 10 companies based on enrollment experienced gains in market share during the period. Anthem realized the largest gain in Medicaid enrollees from March 2021 to March 2022 gaining almost 1.5 million giving them a 10.4% market share.        

 
 


 
 

Note 1: “Renewal of Determination that a Public Health Emergency Exists” https://aspr.hhs.gov/legal/PHE/Pages/covid19-15jul2022.aspx.

Note 2: Medicaid redetermination is the process states use to determines if enrollees in the program are still eligible for benefits.

About Mark Farrah Associates (MFA)

Mark Farrah Associates (MFA) is a leading data aggregator and publisher providing health plan market data and analysis tools for the healthcare industry. Our product portfolio includes Health Coverage Portal™, County Health Coverage™, Medicare Business Online™, Medicare Benefits Analyzer™, 5500 Employer Health PLUS, and Health Plans USA™. For more information about these products, refer to the informational videos and brochures available under the Our Products section of the website or call 724-338-4100.

Healthcare Business Strategy is a FREE monthly brief that presents analysis of important issues and developments affecting healthcare business today. If you would like to be added to our email distribution list, please submit your email address to the “Subscribe to MFA Briefs” section at the bottom of this page.

 
 

Clipped from: https://www.markfarrah.com/mfa-briefs/mark-farrah-associates-noted-more-than-one-quarter-of-us-population-on-medicaid/

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CareOregon helping Medicaid members stay cool in extreme heat

 
 

MM Curator summary

[MM Curator Summary]: The MCO is planning ahead this year to help members avoid heat stroke, using algorithms to identify those most at risk.

 
 

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.

 
 

Enlarge

CareOregon is targeting those who may be at risk for heat stroke.

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With temperatures forecast to sneak into the triple digits this week, CareOregon is reaching out to about 700 members in its Medicaid plan who are at risk of heat-related illness.

The outreach actually started several weeks ago, in an effort to get ahead of the summer heat, in light of last year’s Heat Dome. Nearly 100 people, 13 of whom were CareOregon members, died statewide due to the extreme heat in June 2021. Many were seniors, people with disabilities and people with underlying medical conditions.

“This year, we wanted to start earlier because didn’t want to end up in a super-reactive state,” said Jonathan Weedman, vice president of population health for CareOregon, the largest Medicaid subcontractor under Health Share of Oregon. “We did outreach in early June to start prepping for what we knew would be inevitable.”

CareOregon identified those at risk by evaluating if they had a past history of heat-related illness and if they have chronic conditions. They also used geomapping technology to determine if they live within “heat islands,” or neighborhoods where temperatures rise the most during extreme heat.

“We got more sophisticated and more targeted in terms of the algorithm,” Weedman said.

A rapid response team of nurses, navigators, care coordinators and social workers has been contacting members and asking if they have an air conditioning unit and all their medications. CareOregon is also providing nonemergency medical transportation to cooling centers.

CareOregon does sometimes provide window units, but Weedman said some members are not allowed to have them in their apartments. Since last year’s heat wave, CareOregon has distributed 240 air conditioners.

One person said they had a unit but didn’t want to use it for fear of running up their electricity bill. CareOregon got them some utility assistance, Weedman said.

“There’s the basics, but also problem solving for all these other things,” he said.

Beginning Monday, TriMet will not turn away anyone riding to a cool place who cannot afford to pay fare. Multnomah County provides an interactive map of pools, community centers and other cool community places.

CareOregon manages care for 511,000 members, mostly in the Portland metro but also in Columbia and Jackson counties.

 
 

Clipped from: https://www.bizjournals.com/portland/news/2022/07/25/oregon-heat-wave-medicaid.html

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Humana to reorganize, launches executive search

 
 

MM Curator summary

[MM Curator Summary]: The insurance giant is making big moves in a recent re-org and efforts to cut $1B in costs.

 
 

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.

 
 

 
 

 
 

Humana said it will restructure its organization into two distinct units as it looks to simplify the company’s overall organization, executives told investors Wednesday.

The move will slim the firm down into separate units it will call Insurance Services and CenterWell, building on Humana’s recent acquisition of Kindred amid the push for care at home.

To lead this new segment, Humana has launched an executive search for president of insurance and enterprise services.

The realignment will take effect in 2023 and Humana expects to name a new leader by the end of the year.

Separating into two units will create greater collaboration, a more agile company and will expand the scope of authority for Humana’s leaders, CEO Bruce Broussard said on Wednesday’s second-quarter earnings call.

“We believe this simpler structure will create greater collaboration across our insurance and CenterWell business, and will accelerate work that is underway to centralize and integrate operations within the organization,” Broussard said.

The new Insurance Services unit will be made up of the businesses that sit within the current retail, group and specialty segments while CenterWell will include the current healthcare services segment, Broussard said.

For the new role, Humana is looking for candidates with deep experience in running complex organizations.

“A key focus of this role will be to help us continue to simplify our structure to make us more agile, and to further improve our ability to increase synergies between our businesses and improve outcomes for our customers,” Broussard said.

In other executive changes, Humana said Alan Wheatley, retail segment president, will transition from his role at the end of the year. Humana will begin a search for a new leader with a broader role. Wheatley will serve as a strategic advisor over the next year to help with the transition.

The reorganization follows Humana’s previous announcement in February that it would look to cut $1 billion in costs to reinvest back into the business.

 
 

Clipped from: https://www.healthcaredive.com/news/humana-reorganize-executive-search/628223/?utm_source=Sailthru&utm_medium=email&utm_campaign=Issue:%202022-07-27%20Healthcare%20Dive%20[issue:43390]&utm_term=Healthcare%20Dive

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Senior Business Analyst (Medicaid Programs), Honolulu, Hawaii –

 
 

Job Summary

Ensures that the contractual, regulatory, and accreditation requirements and objectives of HMSA’s Medicaid Programs are identified and met. Responsible for assisting with and supporting the development, implementation, planning, and oversight of activities related to Medicaid program requirements and objectives as assigned under the direction of the Director, Medicaid Administration and Sr. Manager, Government Programs.


Responsible for assisting with communication and coordination with HMSA departments, subsidiaries, and business associates that support Medicaid Program requirements and objectives and also for participating in the evaluation of their performance. Also responsible for assisting with the management of projects related to enhancing existing capabilities or developing new capabilities for the Medicaid line of business and analysis of business information with emphasis on the identification, development, and use of appropriate data and analytical methods for answering specific business questions related to HMSA’s Medicaid Programs.


Minimum Qualifications


 

  1. Bachelor’s (BA) degree and four (4) years of related work experience; or an equivalent combination of education and related work experience.
  2. Effective verbal and written communication skills
  3. Demonstrated knowledge of the operation of managed care programs.
  4. Demonstrated knowledge of Hawaii’s QUEST program or other governmental managed care programs.
  5. Intermediate knowledge of Microsoft Office applications. Including but not limited to Word, Excel, Outlook, and Power Point.

Duties and Responsibilities

Business Solution Development:

  • Develop, maintain and coordinate department user requirements, data reporting and application requirements for projects that affect Medicaid Programs.
  • Assist with solution design and development.
  • Participate in and lead teams involved in projects that affect Medicaid programs and collaborate with project leads and team members from other departments.
  • Communicate and collaborate with appropriate staff to ensure suitability of solutions. Develop effective use of advanced analytical methods and tools to enhance the delivery of solutions to meet business requirements. As required, learn new business concepts and methods applicable to Medicaid Programs projects and initiatives.

Business Project Analysis:

  • Develop and apply appropriate analytical methods to assigned business projects and tasks.
  • Thoroughly document all aspects of project requirements, methodology, task schedule, and analytical results including interpretation of results, summary findings, and presentation reports.
  • Collaborate with staff and management in own and other departments as required to fully understand business scope, business constraints, and business implications of analytical results

Program Management:In support of and with assistance from the Director and Sr. Manager, assist with:

  • Developing and communicating overall project strategy to ensure that business requirements are fulfilled across all Medicaid Programs activities and projects.
  • Ensuring that all Medicaid Program required reports, data, and activities are completed and delivered accurately and on time. Managing all aspects of the planning, execution, and closure of such projects.
  • Evaluating and directing the development of best practices, project standards, procedures, and quality objectives utilizing established project standards, procedures, and quality objectives.
  • Conducting project kickoff meetings and communicating individual roles and project/program expectations and responsibilities to ensure that all project team members have the tools and training to perform effectively.
  • Providing leadership to project managers, project and business leads, and other staff who are assigned to work on Medicaid Programs activities and projects.
  • Developing and maintaining collaborative relationships with Project Stakeholders, Business Relationship Managers, Project Office Managers, and other management and staff as necessary to provide oversight on Medicaid Programs activities and projects.
  • Identifying and analyzing business needs.
  • Translating business needs into appropriate and effective solutions.
  • Monitoring the design and implementation of solutions.
  • Establishing project baselines and developing project schedules.
  • Monitoring project milestones, timelines, technical deliverables, resource usage, critical dates, scope, costs, and quality to identify potential risks.
  • Identifying and tracking project issues and resolutions.
  • Facilitating the resolution of schedule and project related issues.
  • Assessing variance from project plans and implement measures to ensure projects remain within scope, time, cost, and quality objectives.
  • Tracking and reporting project status.
  • Preparing and presenting project updates to senior management and Executive Steering Committees.
  • Preparing and presenting business justification for tactical business priorities as required.
  • Facilitating the evaluation, selection, and contract negotiations for external vendors.
  • Managing vendor relationships in support of project goals.
  • Acting as a liaison between Medicaid Programs department, other HMSA Departments, subcontractors, and vendors.
  • Continuously providing constructive team feedback as is pertinent to Medicaid Programs projects.
  • Integrating, wherever possible, areas of improvement into the project lifecycle.
  • Coaching and mentoring less experienced department personnel.
  • Maintaining content of project websites to facilitate effective communication.

Studies and Reports:

  • Produce concise, structured, and informative data analytic reports summarizing projects, objectives, methods findings of program significance.
  • Document issues, background, data, methods, problems and alternatives, and results.

Other Duties/Functions:

  • Perform all other miscellaneous responsibilities and duties as assigned or directed.

 
 

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