Clay’s Weekly Medicaid RoundUp: Week of April 22nd, 2019

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers- (absolutely incredible album, btw. If you ever find yourself driving all night, listen to this album all the way through)

THREE – COUNT EM’ – THREE PAYMENT MODELS FOR DUALS- Seems like we have some decisions being made on the results of all those FAI/duals demos. Last week CMS sent out a State Medicaid Director Letter pitching 3 options for covering duals moving forward. Option 1 is basically how the FAI demos worked – a 3-way contract with the federalis, an MCO and the state. Option 2 creates some weird thing where states and CMS “partner” to run fee for service programs for duals and share Medicare savings (you know, all those savings that fee for service is famous for). And Option 3 is a wildcard where states can cook something up not on the list. One thing I learned: less than 10 percent of duals are in a model that integrates Care/Caid services today.

SUNSHINE STATE STILL FIGURING OUT HOW TO PLEASE HOSPITAL BIGWIGS BUT LOOK LIKE THEY’RE NOT- Fiscal holdouts in FL have been trying to reduce Medicaid hospital spending by about 3%. That was the opening bid, anyway. Now lawmakers are saying maybe they won’t make the cut if they can get consensus on “resfhuffling” (that’s politician speak for “move the money to where the lobbyists tell me to”) $318M in Medicaid uncompensated care funds. Right now the fight hinges on whether to shell out the moola evenly to all hospitals (with an across the board up in base rates) or to distribute it based on who sees the most Medicaid patients (you know, the ones with the most uncompensated care). Problem is the ones who see the most are probably not the same ones sending lobbyists to the state house.


HANGING WITH MR. COOPER- Good Guvn’r Cooper of NC continues to hold a torch for expansion in the Tarheel State. If you look real close you can see him winking when he says “let’s talk expansion, then we’ll deal with details like work requirements.”


VOLUNTEER STATE EXPANDS MEDICAID FOR DISABLED KIDS, BUT ITS NOT THE TYPE OF MEDICAID EXPANSION LEFTIES WANT, SO CRICKETS- TN House Reps voted to use online shopping taxes to fund more services for more kids using the Katie Beckett waiver. Under their plan, $27M would go to help 3,000 kids with severe disabilities regardless of income. As of now the state Senate is not ok with the plan. So call, or whatever your protest provider of choice is and make sure you get a flood of people with picket signs up in the TN statehouse.


$463M OVER BUDGET FOR MEDICAID, COOL. SPEND TINY AMOUNT TO CREATE NEW OFFICE TO GET SOME BETTER NUMBERS MOVING FORWARD? RESIST!!- Officials are still double-dog promising that the nearly half-a-billion overspend on Medicaid had nothing to do with expansion (they just happened to occur roughly at the same time). Even if that absurd claim were true, you would think a bill to establish an Office of Independent Medicaid Numbers (not the actual name, but you get it) would sail through. It did in the house, but not the senate. In case you need a reminder, taxpayer, your job is to pay, pay, pay. To ask for better oversight is downright Deplorable.


GOTSTA PAY BACK THAT CASH NURSING HOMES- Rhode Island fronted about $84M to nursing homes when they were working out problems with the application system. Now the loan has come due, but the nursing home lobby is saying they need more time (and they are suggetsing that the backlog might happen again). Loan repayments start in May, and they are supposed to pay most of it back by June 2020.


CONGRATS TO SOFTHEON IN WV- They just went live with their asset verification tool that integrates with the Medicaid eligibility system to check assets for Medicaid and SNAP applications. Out of 560,000 Medicaid bennies in WV, 350,000 also have SNAP so the overlap will help drive significant processing efficiencies for both programs.


KEYSTONE STATE CHECKING UNDER HOOD OF MEDICAID PROVIDERS- So this is new. The PA auditor general announced he will be randomly auditing Medicaid “contractors” (ie providers that are not docs) to make sure monies are not being wasted in the $33B program. Out of “thousands” of contractors, 6 will be in the first round of review.




THE MEDICAID BLACK BOOK IS HERE- Want to know what’s on the mind of MCO CEOs? Want to see our in-depth reviews of vendors? Current issue is out. You can check it out here –

COME HANG OUT IN BALTO IN MAY– I’ll be speaking and generally gallivanting at the Medicaid Managed Care Congress May 20-22nd in Baltimore. Would love to see you there. 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. Jennifer Lynn Robinette of Gwinnett County, GA plead guilty to stealing $800K from residents of her Wishes 4 Me facility (housing people with physical and intellectual disabilities). She convinced them to open joint bank accounts and then took the cash. What’s the Medicaid connection? Ultimately the cash was from the GA Medicaid Independent Care Waiver Program. Move west on over to Baton Rouge, LA where we have a sizable member fraud. Naji and Shifa Abdelsalam failed to disclose their income from multimillion-dollar businesses and got about $74K in Medicaid benefits. Fun fact – one of the businesses they own is Five Star Medical, a Medicaid transport company. And – wait for it – they were stealing Medicaid bucks with that, too. Stick in LA for a moment more – Latoyia Porter of Covington, LA operated Walk With Me. Seems Walk With Me may have stolen more than $100K in Medicaid bucks by charging for counseling sessions that were not provided (or provided by underqualified staff). Now lets scoot on up to Maryland (but still below the Mason-Dixon line), where we find a case in which 5 cardiologists stole $81K by double-billing for similar procedures. In addition to testing for vein sufficiency (somebody with medical letters on their profile please comment what that means), they also billed for an older test for the same thing. Finally, let’s fly on over to Springfield, MO where we meet James Dye. Mr. Dye (technically Dr. Dye, which phonetically is much more ominous) was a dentist who stole $165k by billing $50 mouthguards as $700 “prosthetic devices.” Dr. Dye- you win on sheer hutzpah alone. Taxpayer, you know the drill.

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 (stare at the ground and watch seedling sprout, its good for the soul and better than checking email) and keep running the race (you know who you are).

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