Clay’s Weekly Medicaid RoundUp: Week of July 25th, 2016

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SUCH A HISTORIC WEEK – Unless you have been under a rock (or perhaps engrossed in your Pokemon Go! adventure), you know this week saw a very historic milestone for our nation. Yes, dear readers, I am of course referencing the fact that a single healthcare fraud topped $1B for the first time ever.


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. Philip Esformes of Miami has set the world record with his $1B fraud robbing taxpayers who fund Medicaid. Esformes used his 30 nursing homes to bill for unnecessary procedures for Medicaid bennies. $1B people- $1B!! That’s 15,384 teachers (at an average annual salary of $65k). Heck, that might even cover 1 month of ACA premium increases. Staying in Miami for a moment, Fernando Mendez-Villamil was sentenced for 12 years for defrauding Medicare and Medicaid out of $50M. How did he get caught? At some point, he got on Chuck Grassley’s radar who noticed Mendez-Villamil wrote 96,685 scripts over 2 years for Medicaid bennies alone. Let’s head northeast to Chicago, where Gregory Toran was convicted of stealing $4.7M from Illinois Medicaid using his transportation company to bill for rides for dead people and for live people who never actually took rides. Now lets’ go way northeast on up to Anchorage, AK, where Mee Chong Collins stole $320,336 from Medicaid using false personal care services claims filed under her “Sunshine Care Services” company. Let’s move back towards the heartland, where Wendi Baker of Tiffin, OH was indicted for stealing up to $300k from Medicaid while working as a nurse at Blanchard Valley Health System. Hop on over to Oregon with me, as we watch Anthony Neal plead guilty to stealing $1.7M from Medicaid by using his clinic to order unnecessary tests. Total RoundUp reported fraud tab this week (not including the historic $1B from Mr. Esformes): $57M. Of course, Mr. Esformes, you win this week’s award!


WOW, JUST WOW- So much happened in the fraud space last week (much of it likely tied to another one of those coordinated drag nets we’ve seen the past few years), its almost difficult to think of much else. In the spirit of innovation, I will leave you with the rest of this week’s Medicaid news, in traditional haiku form (5-7-5):


News Item 1

Supplemental rule

Leaves OMB, goes to Prez

Cash this way rising


News Item 2

Bad times for Alere

Investigation slows buy

Kickbacks, fraud – oh my!


News Item 3

BlueGrass state looks back

Before leap, before Beshear

Plays chicken with feds


News Item 3

Public option lives!

Policy wonks remember

Prez gave C-P-R


News Item 4

Wolverine State plans

In the money, man oh man!

ACA cap rates high?


News Item 5

Brandstad marches on

Tells Dems and press to stuff it

Growing pains, he says


News Item 6

Anthem beats forecast

CIGNA deal still taking time

But rolls grew half-mill


News Item 7

UHC, Aetna

New Cal-forn-ya MCOs

Congrats on the win!


News Item 8

Caid’ Rx report

Abilify, Sovaldi

And Vynase top list



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 (its time to start planting a second crop!) and keep running the race (you know who you are).


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News that didn’t make it and sources for those that did: twitter @mostlymedicaid
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