Clay’s Weekly Medicaid RoundUp: Week of April 1st, 2019

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-

IT WAS 50 FEET TALL AND CAME FROM ANOTHER PLANET! ATTACK OF THE GIANT MCO!! In case you haven’t heard, Centene is gobbling up WellCare for $17B. Will make them the biggest MCO in the universe. To be honest I was surprised- WellCare was doing well marching to the beat of its own drum (and I like that sort of thing). I am sure it will take a year to placate deal-reviewing bureaucrats, and probably another year before its really seen in market facing roles. And by then all MCOs will be sold to the new Walmart-Amazon-Costco conglomerate…

UHC IOWA EXIT- Not a lot of friends made by UHC on this one. UHC is filing for a divorce from Iowa Medicaid (more like just walking out and leaving the keys on the table by the door). There is a Dear John letter, though. You can read that here. Basically they blame the rates and go so far as to suggest a new way of doing the math. Surely it makes it a little easier on UHC to bail since AmeriHealth Caritas did it in October 2017- but I promise states don’t forget this type of thing.

WELL WE TOLD YOU THE NEW SYSTEM WAS GONNA FIX THOSE CRAZY BIG INELIGIBLE NUMBERS- Remember the stories of LA Medicaid paying like bazillions of Medicaid bucks for members who were not eligible? And remember that the answer was the tried and true “yeah, but the new thing is gonna fix it.” Looks like that was true. Louisiana’s new eligibility system dropped more than 30,000 people from the rolls this week. Almost all of them are non-elderly, non-disabled adults brought in under the Good Guvn’r Bel Edwards ginormous expansion in 2016. Secret sauce to the stronger, more accurate eligibility system in the Pelican State? It does quarterly checks (instead of sorta-kinda-maybe-annual ones) and uses more wage data to verify income.

ALASKA, IM GOTTA ASK YA– I totally did just make a rhyme with “Alaska”. How many times have you seen that in your life? (or heard that, I guess?). Well anyway, the thing I gotta ask ya, Alask-ya (its getting better by the sentence, isn’t it?) is – do you think you really will be the first state to convert your Medicaid program to a block grant? AK Good Guvn’r Dunleavy sent POTUS a letter asking for just that on March 1.

UTAH TO VOTERS- “WE DECIDED TO GO A DIFFERENT DIRECTION” – Seems conservative citizens aren’t the only ones who get screwed by their representatives. Lefty voters in Utah selected “lots more Medicaid at full ACA rates” on their ballots last year, but instead are getting a good bit more Medicaid, at 100% FPL levels. This could be the first “limited expansion” we keep hearing about, and that Verma is now letting us know CMS could be open to. (See also stories about the GA request).




THE MEDICAID BLACK BOOK IS COMING- Want to know what’s on the mind of MCO CEOs? Want to see our in-depth reviews of vendors? Next issue comes out 4/15. You can see our latest explainer video for it here –

COME HANG OUT IN CHICAGO END OF APRIL- I’ll be speaking / chairing the 4th Annual Medicaid Managed Care Leadership Summit, April 29-30th in Chicago. If you are interested in going, send me a note so we can coordinate, and I can also get you a 15% off registration. Check out the event here-




FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. The paragraph taxpayers love to hate. Let’s start the ticker and see who wins this week’s award. Frank and Melanie Palcic of Pueblo, CO stole about $1M using their speech therapy service to submit bogus claims. Kevin Schaul of Springfield, MO was sentenced for his pilfery totaling $600k. How did he do it? False claims to Medicaid for incontinence products. Liem Do and wife Phuong Tran of Clark County, WA were ordered to pay $1M back to Medicaid for a long list of dental frauds. Looking for a good early summer fraud trial to watch? Head down to Miami, where Philip Esformes is on trial for a $1B Medicare and Medicaid fraud. Mr. Esformes is charged in a gigantic kickback scheme related to his network of assisted living facilities. This story even has a sub-plot about him paying a university to let his kid in, so you can get some of that good buzz from the current celebrity college fraud scandal, too. Mr. Esformes is fighting it though, so the drama will be high. One thing cool from this story- I learned that its so bad in Miami now, the city has actually become known as the “healthcare fraud capital in America.” Jeffrey Terry of Mangum, OK was indicted this week for using his pharmacy to steal $1M (from both Care and Caid). What did he do? Submitted phony claims for drugs that were never prescribed to patients. And finally, we come to Rose Presser of Milwaukee. Rose used her mental health clinic to steal $4.1M from Medicaid by running unnecessary urine tests through her substance abuse treatment program. So, if you were ever wondering if you can literally p*ss away $4.1M – you can. This week’s award goes to husband and wife team The Palcics. I just love a good love story, don’t you?

Need even more Medicaid fraud stories? – You can get your fix in the FWA Curator archives.

Want to read the articles summarized here, highlighted for your reading pleasure? Check out the News Curator archives.

That’s it for this week. As always, please send me a note with your thoughts to or give me a buzz at 919.727.9231. Get outside (prepare garden beds; it won’t be long and we can plant!) and keep running the race (you know who you are).

FULL, FREE newsletter@ . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: UBawo wathumela uNyana ukuba alondoloze ihlabathi