Clay’s Weekly Medicaid RoundUp: Week of May 20th, 2019

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-


KNOW WHY YOU GET TO GRILL BURGERS ON MONDAY? Because brave soldiers died protecting you from threats home and abroad. Take a moment to learn about a few heroes who died recently-


OKIES DARING TO FOLLOW REGULATIONS AND CHECK ELIGIBILITY BY MAIL- In order to make sure the member rolls are accurate (sort of an important thing, especially in managed care states), CMS requires states to, you know, verify members exist. Part of that involves attempting to contact them. Attempting to contact them by mail is how CMS suggests to do it. Oh yeah- it also proves you live in the state (a term called “residency”). In the never-ending story of making it impossible to actually be a good steward with hundreds of billions of dollars, #Resisters in OK are ticked about a proposed rule to take bennies off rolls if the letters they send are returned undeliverable. Next year all it will take to get a Medicaid card will be to wish upon a unicorn’s left hoof and “poof” – you’re in!

CMS JOINS SPREAD PRICING FRACAS- Last week the Big House released guidance to states and plans about how to view spread pricing and MLR. The gist – it does impact MLR and any vig that an MCO paid to a PBM via spread pricing does NOT get to count as medical costs. Go figure.

LEARNING MORE ABOUT NC SDOH PILOTS- Key things you need to know: $650M will go to pilot programs for 50,000 bennies ($13k/each for Roundup Readers playing at home). Programs will address housing, transportation, food, and interpersonal violence. MCOs will manage the budgets for each benny in the pilots. RFPs for the Lead Pilot Entities (LPEs- the network builders) expected round about Thanksgiving.

BYE, MR. TRAYLOR- Chris Traylor, current head of the CMS Medicaid and CHIP services unit, will be stepping down on May 31. Calder Lynch (who did our state spotlight show a few years back) will be acting director.


BUT, YOU SEE, IT DOES FURTHER THE GOALS OF THE PROGRAM- When we’re not blowing money on people who don’t care enough to comply with paperwork, there’s more money to help the sick people on Medicaid waiting lists. At least that’s the argument being made in the Trump Team’s appeal of the work requirements lawsuits. Keep in mind the argument in the suit that slowed work requirements was that they did not further the goals of the Medicaid program. By showing how the new requirements do further the goals for the people who need it most, Team CMS has accomplished what in policy debate is known as a “Turn.”  Or maybe they’re obstructing some sort of Russian dossier under the emoluments clause of the 32nd amendment or something. Who knows? Rachel Maddow, that’s who.


ANOTHER OH MCO DROPS CVS- Buckeye Health dropped the drug giant this week. Caresource led the way a few weeks back.




THE MEDICAID BLACK BOOK IS HERE- Want to know what’s on the mind of MCO CEOs? Want to see our in-depth reviews of vendors? Current issue is out. You can check it out here –

Companies reviewed in current issue:

  1. Apixio
  2. CareCentrix
  3. Digital Harbor
  4. HealthCrowd
  5. InComm
  6. Lucina Health
  7. Medical Advantage Group
  8. Moms Meals
  9. NowPow
  • Vheda Health




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. Sort of a slow fraud week, so your chances of winning are higher. Hellen Kiago, of Sturbridge, MAH was convicted of stealing $2.5M from MA Medicaid. Her crime? She used her home health agency to bill for unnecessary services and falsified documents. Fun fact- once the coppers searched her office, she wired $1.5M to Kenya. Alejandro and Alexander Jiminez-Incera of Las Vegas were sentenced for stealing $3.7M from Care and Caid. They got caught because of a cash-for-opioids operation they were running, then investigators caught onto a bigger fraud where they were billing for patients they never saw.  Margaret Williams of Anchorage, AK was sentenced this week. In addition to getting one of her nursing home staff killed by having them work entirely alone amongst 5 residents with violent records, and not reporting the death within 8 hours, Maggie stole $1M from Medicaid by billing for services not provided. The Lifetime Movie is due out next week. Mrs Kiago – you win this week’s award for quick thinking in times of pressure. Taxpayers – shut up and smile while you watch your money go down the drain.

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 (water and weed, water and weed) 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 .

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