Clay’s Weekly Medicaid RoundUp: Week of March 13th, 2017

Soundtrack for today’s RoundUp pessimist readers-

Or you can click the one for optimist readers –

Both are St. Patrick’s Day references. If you know why, do write in.


ONLY A FEW MORE WEEKS UNTIL MEDICAID STAR SEARCH– A plug for our upcoming Medicaid Star Search Webinar on April 3rd. Sign up here-


MAYO HONCHO JUST COMES OUT AND SAYS IT- Mayo Clinic’s CEO said privately insured patients will go in front of Medicaid patients, assuming comparable conditions. Both will be seen, but the one who generates more revenue will get seen first. The CEO was heard saying something about needing to keep making money to keep the lights on, and to help subsidize free care – but he was carried off by the villagers with pitchforks before reporters could understand him.


ANTHEM DISTINGUISHING ITSELF FROM REST OF PACK IN POLITICAL ARENA- Last week Anthem was the lone wolf supporting AHCA (AHIP and others came out against it). Now we have news of Anthem CEO Swedish meeting privately with President Trump and Price. The meeting (we expect Rachel Maddow to leak the transcripts next week) covered detailed design elements of the bill, and ideas Anthem has on how to improve it.


THE MEDICA STORY SEEMED TOO GOOD TO BE TRUE– Although at first it looked like an amicable exit,  it turns out the departing MN MCO ain’t going down without a fight. It gets a little convoluted, but basically Medica is arguing that the state did not have a right to transfer its membership to other MCOs without a rebid of the contracts. Seems Medica wanted to pull out saying the rates were not actuarially sound, and then perhaps trigger a rebid which would re-open rate negotiation. The state was more than happy to skip that route and just dole out the remaining membership to the remaining MCOs using rates that were established in 2015. These protests are getting harder to follow  than all the crazy drama of the English wars for the throne in the Middle Ages.


HHS HEAD PRICE SAYS LOSING $BILLIONS WON’T HURT MEDICAID- There’s a lot to chew on in that idea. Not the least of which is the loss to fraud each year, paying for poor quality and other obvious areas to trim. I think this quote from Price should be the starting point of this discussion: “You’re falling into the same old trap of individuals who are measuring the success of Medicaid by how much money we put into it.” Ouch. And Amen.



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.  Ethel Freeman-Nnonah and Tinisee Harris of Reynoldsburg, OH were convicted this week of stealing $101,000 by forging medical assessments and plans of care for patients treated by their business (Prudent Healthcare Services, LLC). “Dr.” Stanley Marable of Valdosta, GA will spend 2 years in prison for his role in pilfering $789k by getting paid for tooth extractions that didn’t happen. Tammie Sensenig of Lancaster, PA plead guilty this week to stealing $84k using Medicaid claims for mental health services she provided but was not qualified to render. “Dr.” Romeo Pavlic of Spokane, WA will pay $300k to settle claims he defrauded Medicare and Medicaid by billing for tests he did not perform on developmentally disabled patients. Stanley – You win!



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 (The weekend will be warmer.) and keep running the race (you know who you are).


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