Clay’s Weekly Medicaid RoundUp: Week of March 4th, 2019

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-

OPIOID COURSE GETTING RAVE REVIEWS-Want to understand the opioid crisis? Our newest online course will help. Check it out here-

COME HANG OUT IN CHICAGO END OF APRIL- I’ll be speaking / chairing the 4th Annual Medicaid Managed Care Leadership Summit, April 29-30th in Chicago. If you are interested in going, send me a note so we can coordinate and I can also get you a 15% off registration. Check out the event here-

HMM, NOT SURE YOU REALLY UNDERSTAND THE PROBLEM MS. LIGHTFORD- Gifted health policy expert (and Democratic Illinois Senate Majority leader Kimberly Lightford) took to lambasting MCOs this week for “threatening the very future of our health care providers and the patients they serve all around this state.” Their crime? According to Lightford, excessive claims denials that are coming in around 26% (MCOs say its less than 11%). Compared to the 1-2% denial rate (aka as total failure to manage costs and just pay freakin everything) before the state implemented managed care, 11% suggests maybe there are at least a few more controls in place. But the real root cause – just maybe- is that the state of Illinois has been in default to the tune of billions to MCOs multiple times over the past several years. Hopefully the MCOs won’t get caught holding the bag for the dumpster fire that is Illinois state budget “management.”

IOWA WORK REQUIREMENTS BILL MOVES FORWARD- Would likely apply to the 172k members added as part of ACA, but if it goes like any of the rest of them have the vast majority will be exempt from the requirements.


TX SETTLEMENT WITH XEROX MAY ACTUALLY END UP COSTING LONESTAR STATE MORE THAN THE PAYOUT- Turns out when you pay the feds back their $133M (it is mostly federali money that states blow, remember?), and the whistleblowers (who may get $50M or so) and the attorneys, that $236M payout dwindles down pretty low. Clearly, its just not worth it to fight fraud, waste or abuse in Medicaid. Can we just pay everybody what they ask and move on to saving the world, please?


PROVIDERS NOT HAPPY TO BE MAKING LESS MONEY IN NY- Cuomo can’t seem to make up his mind. A few weeks back he was taking off some spending restrictions (the one where Medicaid payments have to come in under a healthcare inflation index), but this week he’s talking about taking $567M out of the Medicaid budget. And providers (mostly nursing homes and ambulance moguls) are ticked. If you haven’t ever worked closely with the ambulance lobby, you are not familiar with how dramatic they can be when their billing codes are under fire. According to the NY ambulance lobby, the proposed rate cuts create an “impending collapse of the statewide ambulance industry.” Uber for EMS, anyone?


KANSAS QUANTIFIES COSTS OF EXPANSION- Depending on if you believe the “Medicaid expansion as economic stimulus” argument, KS economists are pricing expansion somewhere between $520M to $1B over 10 years. Year 1 will have lawmakers passing the hat for about $47M more to cover expansion.


MAINE OPENS NEW CALL CENTER TO DEAL WITH EXPANSION APPLICATION VOLUME- Western Mainers will notice a new call center opening up this week to house 45 call reps. There are about $1M in new outreach costs for the recently passed expansion. Timing is good – Barclay’s is closing a call center end of this month, so at least some of the 200 people getting laid off there will be able to slide on over to the new Caid Call Center. That will be an interesting switch in scripts for the reps… going from “Hi, I’m calling about your Barclay’s card..” to “Hi, I’m calling about your Medicaid card..”


SHOW ME STATE CONSIDERING CHANGE TO POLICY ON PAYING FOR MEDICAID FOR INMATES- While many of you who work the Caid/criminal justice overlaps already know about the benefits of changing policy to just suspend Clay’s caid benefits when he goes in the slammer (vs terminating them), MO is clue-ing into this. It makes it easier to turn the benefits back on (and off and on and off depending on the recidivism profile of the bennie) once Clay gets back out. And it could help him stay free if it means he gets opioid treatment, help finding a job or various other things Medicaid is evolving to provide.

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. Everado Villareal and Delilah Robles of Mcallen, TX got charged with stealing $850K in TX Medicaid bucks. Their crime? A DME scheme in which they paid a partner to steal Medicaid bennie IDs so they could submit bogus claims for incontinence supplies. Eliza James of Lansing, MI stole $200k using her role as a state HHS worker. She would refer Medicaid members to providers she knew and then approve services for the members. Then the providers would deposit money in her account (so a basic kickback scheme). Steven Baraban of Kansas City stole $9.5M using a scam in which he got paid by MO Medicaid for pain creams and antibiotics that never made their way to members. A whistleblower got $1.5M on this one, by the way. Sort of a slow fraud week, but some interesting small time benny frauds in the Curator if you want to check them out. Mr. Baraban, you are the clear winner! Congratulations!

Need even more Medicaid fraud stories? – You can get your fix in the FWA Curator archives.

Want to read the articles summarized here, highlighted for your reading pleasure? Check out the News Curator archives.

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 (prepare garden beds; it won’t be long and we can plant!) and keep running the race (you know who you are).

FULL, FREE newsletter@ . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: uBaba wathumela iNdodana ukusindisa umhlaba