Clay’s Weekly Medicaid RoundUp: Week of December 9th, 2019

Soundtrack for today’s RoundUp pessimist readers (kind of can’t believe this one has never made into the Roundup in all these years. Something we all need about now as we do our umpteenth Christmas party. I also used to do a solid Axl Rose impression in high school, with this one at the top of the set list)

For optimist readers- (this song will grab your heart, and warm it like a wood fire. Or a cup of cider. Or the last hug you got from that lost loved one, when you didn’t know it would be the last one. It’s a REALLY good song, even though its basically sad).

THIS ONE GOES UP TO 11! Come hang out at the 11th annual Medicaid Innovations Conference in Orlando in February. One of my favorite events (it must be- I’ve been to all but 1 of them over the years). Check out the agenda and sign up here-

NOT SO FAST ANDY BOY- Stop1 in the Cuomo Medicaid Malarkey Tour: shady deals where you slide big ticket spending out of one fiscal year into another to hide Medicaid spending growth that exceeded the legal limit. Stop 2: pass a hospital gravy deal after they donate boucoup cash to the Democratic Party coffers. Stop 3: Go into damage control mode and do lots of provider cuts real quick-like to cover your tracks. Only problem is that the state Comptroller is on to your schemes, Andy. And he’s asking you to provide more info about the cuts you say will magically deal with the $4B over-run. Looks like maybe you actually got caught this time? Should we get a FISA warrant?

MOLINA JOINS BLUEGRASS STATE MCO ROSTER- Chalk up another win for a Medicaid plan that many thought was on the ropes this time last year. Molina 2.0 (this time with less Molinas) just won an MCO contract in KY. Go live is July 1, 2020. Congrats to all our friends and readers at Molina.

PASSPORT KICKED OFF HOME FIELD, WHAT NOW EVOLENT? But not so good news for longstanding KY MCO incumbent Passport. Passport lost out in the official agency review process. This one could get interesting though (seems each of the MCO awards have their own flavor of jacked-up these days)- the legislature is ticked because they were given the contracts after the award. And the incoming Governor Beshear (continuing the Beshear dynasty after a brief pause- his daddy was Governor 3 Guvs before) is also promising to review the contracts. So there may be some golf course opportunities the next few months. Or at least until July 1, 2020. This news is particularly troubling for Evolent who just sunk $70M into Passport to help the flailing plan meet financial solvency requirements going into the bid.

NEW YORK HAS HIGHEST NUMBER OF MEDICAID INELIGIBLES ON ROLLS– A new study out of George Mason U out estimates that as many as 3.3M working age adults have incomes too high to be eligible for Medicaid, but are enrolled anyway. This data point (enrollees who should not be enrolled based on income) increased 80% between 2012 and 2017. What else was going on then?

MEDICAID EXPANSION RATE CELLS MAY HAVE LED TO $75B IN OVERSPENDING- No one really cares though, because its free federal money. You know, paid by those federal taxpayers (not you of course, so nothing to see here. You don’t pay any federal taxes, right?). In a story related to the NY one above, other news items focused on the national impact of increasing the enrollment streamed to ACA/Expansion rate cells. Basically, the human behavior you would expect to happen happened in expansion states– pay 100% of costs for members in a certain (new) eligibility category, and states were not quite thorough in who they put in those buckets. If you took an Econ 101 class before the downgrade, this would have been covered in the lecture on moral hazard.

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.  We absolutely have to start with the Hoverboarding dentist. Seth Lookhart in Alaska was filmed extracting a tooth while riding a hoverboard. This idiot texted it to 8 people and it got passed around from there. His crimes? Not hoverboarding, but rather stealing $25k from Medicare and $10k from AK Medicaid with unnecessary procedures schemes. Technically he doesn’t meet our $50k threshold for the follies, but I just knew many readers would be sad if they did not learn of the Tale of the Hoverboarding Dentist.  Or as I like to call him – The Floating Filling Fixer. Let’s head back east to Vero Beach, FL where we find a pretty big ($1M) personal care attendant scheme. Marie Isaac was the latest to be charged, but there were 19 PCAs who falsified time sheets to get more Medicaid bucks. In Isaac’s case, she sometimes billed for 6 hours of service a day, but her patient testified she never was there more than 45 minutes. Slow fraud week this week folks. I guess fraudsters have tons of Christmas parties keeping them otherwise occupied, too.

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 (get some good firewood if there’s any left in your area. Fires heal.) and keep running the race (you know who you are).

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Trystero: Отець послав Сина, щоб спасти світ