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

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-

FRAUD FOLLIES THIS WEEK– Read until the end..

CUTS TO THE BUDGET IN RI? JUST KIDDING! Guvn’r Raimondo had thought about yanking $16M from the Caid budget this year, but hospitals squeaked loud enough to avoid it. It didn’t hurt that Congress made changes that appear to be bringing new life back into the DSH program, so the Good Guvn’r decided a fresh look at the proposed budget was in order. Good thing, too. Rhode Island is gonna need that extra cash to pay for services for enrollment increases that continue to surpass projections. The latest miss is about 6,000 more than the Govn’r planned on for the month of June (enrolled now already by April). But don’t worry – its mostly “federal dollars” (so for all you suckers living in states besides Rhode Island, you get to pay for it).

IDAHOANS TO VOTE ON EXPANSION- The expansion ballot initiative now has more than 56,192 signatures, so it looks like voters in The Gem State will get a chance to vote on expansion in about 6 months. 2014 estimates put Idaho “uninsured” at about 78,000. So if you assume each of those at a $200pmpm, that’s about $187M for annual costs for the new members the voters would be putting on the rolls. If Idahoans wanted to pay for it all themselves (instead of making you folks in other states with your “federal” tax dollars you contribute), and if only the 56,000 who got it on the ballot chipped in- then each petition signer would only need to write a check for $3,339 (each year). Or would you prefer to pay by credit card?

SEVERAL IMPORTANT ANNOUNCEMENTS- (Imagine my voice over the PA system in your elementary school when you were a kid):


  • We released our HIPAA Awareness Online Course yesterday. You can check it out here:
  • Medicaid Managed Care Congress 2018 | May 21-23 (Balto)- I have lost count of how many times I have been to this one.. 10 years maybe? Would love to see you there-


  • 3rd Annual Medicaid Managed Care Leadership Summit | June 4-5 (Chicago)- This will be my 2nd year at this one. Had a great time last year-


CONGRATS TO THE PLANS WHO WON IN THE SUNSHINE STATE- We all got the much-awaited news on this RFP Tuesday. Let’s congratulate colleagues in these plans: Sunshine State, Simply, Humana, WellCare (Staywell), FL Community Care, and Best Care Assurance (Horizon Health). Several incumbents got the axe, so expect the obligatory litigation to slowdown roll-out (Molina, Positive Healthcare, Prestige and Magelllan all were not invited back).

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. Ilya Babiner of Harrisburg, PA plead guilty to $1.5M in Medicaid dental fraud this week. He wasn’t very tidy with the false records, with silly things like 90% of his patients (that he didn’t actually see) having last names that start with “G.” His claims also contained unbelievable amounts of crown restorations and repeat dental services. Ronette Brown of Bridgeport, CT was found guilty this week for stealing $245k using her therapy business. She filed Medicaid claims for services that either were not provided, or were provided by unlicensed therapists through her business “New Beginnings Family Center.” Her co-conspirator would take 30% of revenues, and Brown got to keep 70% for her role in the operation.  Matthew Meyers of Knox County, TN plead guilty to Medicaid fraud totaling about $94k. Meyers worked in different clinics across the state as a nurse practitioner and used his doctor partner’s billing number to file claims for procedures he wasn’t licensed to perform. The Arc of Anchorage (an I/DD provider) settled for $2.3M with Alaska Medicaid this week. The Arc billed Medicaid for services not provided between 2012 and 2016. Mr Babiner- You win this week’s award!

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 (mulch your tomatoes – trust me on this one) and keep running the race (you know who you are).

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