Clay’s Weekly Medicaid RoundUp: Week of August 27th 2018

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-


I WILL BE AT MHPA 2018 IN OCT., WILL YOU? You can check it out here –

If you are going, please let me know. I absolutely love to meet RoundUp readers in real life.

MAYBE LONESTAR STATE PULLING THAT MCO RFP RECENTLY IS MAKING MORE SENSE? TX providers gave legislators an ear full on Wednesday. Many tales of provider woe from meanie MCOs, including delayed payments, more paperwork and tighter utilization control. Providers also complained that there are not enough agency staff, and the program is underfunded. This is an easy fix, guys – more money! Duh, Wilberforce.

MISSOURI PHI BREACH FOR 19,750 CHILDREN- WellCare sent letters reminding kiddos (or their parents) about the need for well child visits- but they sent them to the wrong addresses. Seems to be a recurring problem, with a similar breach involving 1,223 member letters last year.

ADD THE MOUNT RUSHMORE STATE TO LIST OF THOSE ASKING FOR WORK RQUIREMENTS- South Dakotans have spoken (through their duly elected representatives, unless of course Russia swung recent SD elections, too. You never know. I was talking to John Stewart at an Antifa potluck he and I were both at last weekend, and he says the Ruskies swung SD. And I like to get all my political analysis from celebrities. Totes) and they want CMS to allow work requirements for their Medicaid program, too.

 NEBRASKA JUDGE OK’S MEDICAID POLICY BY BALLOT; MEDICAID DIRECTOR ROLE NO LONGER NEEDED- Two state lawmakers had tried to head it off at the pass, but no dice. A judge ruled this week that Medicaid expansion can go to the ballot. Hey voters- which DRG grouper do you think we should use next year? Also, we need to update our CMS-34 reports to pull down the additional funds needed. Do you think we should check box 1 or 2 on section F? Would love your opinion…Cuz y’all are totes awesome Medicaid geniuses.

 TRYING TO DEAL WITH OPIOID CRISES IN OREGON IS TRICKY- New plan to make current chronic pain opioid users taper down to zero over 12 months is not without its detractors. That is a best practice, by the way (at least based on some of the research we are using in our upcoming Understanding the Opioid Crisis online course).

 TN HOSPITAL SUES STATE SAYING IT FAVORS MCOS OVER PROVIDERS- Erlanger Health System in Chattanooga (man that’s a fun word) has sued TN over payment rates to hospitals. Looks like a 2007 law requiring MCOs pay the average in-network rate for Medicaid ED visits may be getting interpreted to be the lowest in-network rate instead. Here’s my question – How do the hospitals that’s suing know any of the rates besides their own? Isn’t that secret-sauce, MCO/provider contract stuff?

FL MCO AWARDS COURT CASE STILL GOING- I thought this was over, but the AIDS Foundation plan that lost out, and the South Florida Community Care Network are still pushing for either a new RFP or new awards (for themselves). You know the old- “do the right thing or favor us. Whichever one comes first, we’re cool with as long as it favors us.”

CA MAY PAY FOR TELEHEALTH FOR SUD TREATMENT- Perhaps seeing IL do a similar thing, CA Good Guvn’r Brown is planning on signing a law that will allow for substance abuse counseling sessions via telemedicine (think a Skype session with your therapist).

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. East Mental Health of Roanoke, VA may get off this time due to prosecutors not meeting a discovery handover deadline in this $45M Medicaid case (there are 3.5M documents to wade through). Christopher East (the owner) is charged with 73 counts of tomfoolery, including making up claims and records needed to nab the Medicaid bucks. Helen Balding and Robin Raveendram – who operated the fairly high-profile Arkansas Preferred Family Healthcare scam – were arrested on Medicaid fraud charges in the past few weeks. Looks like Robin was the brains behind the operation, instructing employees VIA EMAIL to forge $2.3M in claims. Michael Gaines of Baton Rouge (Red Stick for all you parents of curious children) was collared as part of the ginormous federal healthcare fraud sweep recently (along with 20 other defendants in the town). He stole about $2M as a social worker by submitting bogus claims for group therapy for students. Matilda Prince of Mineral Bluff, Georgia was sentenced to 3 years for stealing $1.2M from both Medicare and Medicaid. She billed for optometry/ophthalmology services never provided. Melissa DeLap of Jefferson City, MO was sentenced this week for stealing $106k by falsifying personal nursing claims for 4 Medicaid members. One of the people she supposedly provided care for died in Sep 2016 but was not even reported missing until April 2017. Mr. East, your strategy of “drown em’ in documents” put you over the top and you win this week! Taxpayers, you lost about $51M just in these cases that made it to the news. Keep working hard!


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 (plan your winter garden/greens) and keep running the race (you know who you are).

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