Clay’s Weekly Medicaid RoundUp: Week of November 12th, 2018

Soundtrack for today’s RoundUp pessimist readers-


For optimist readers-


MEGA RULE MUTATES- After a loooooong windup and much speculation, CMS finally showed its cards on possible changes to the Mega Rule. (Do you get the feeling they wait until early November for big stories just to make sure there are interesting convos in the NAMD hotel happy hours?) Highlights: Possible relief on cert for all those rate cells (may go back to ranges), 3 years to put on your big-boy pants related to pass-through payments, and more grace on using telehealth to meet network standards. And oh yeah – some stuff about making sure all you turkeys stop using different rate cells to game the federal match.


IL CRIES UNCLE- Following many other states (who are following judge’s orders in their own states), the Land of Lincoln (R-IL) has decided to open the floodgates on Hep-C coverage. Now no signs of disease or proof of sobriety are required to get the pills that cost about the same as a souped-up Civic. But hey- it used to be a new Vette.


MICHIGAN GETS TREATED LIKE AN ADULT- Add a W to the win column in the “restore a modicum of power back to the states game.” CMS approved Michigan’s request to negotiate their own deals for pricy drugs based on whether they actually work for the patient. This CMS approval comes 4 months after a similar gig for OK and a denial for MA. Right now the MI deal is focused on 4 drugs. I’m sure the list will expand, and if you say the magic words – “value-based-care,” “population health,” and“big data,” – four times fast, under a fool moon, wearing green slippers, the list of the next 4 drugs will magically appear in your left hand (if you’re left handed; else, your right hand).


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. Idris Talib of Columbia, SC got five years in the slammer for stealing $400k using false claims for counseling. Head on up 1 state to NC, where we meet Renee Borunda, who managed to steal $225K using another therapist’s billing ID for Medicaid claims that didn’t happen. Keep heading north until we get to Niagara Falls, NY (cool place if you haven’t ever visited), and we learn about Sadat Khan who used Wego Taxi Tours to steal $50k from Medicaid. How did he do it you ask? By falsifying pickup location addresses so the trips would appear longer and get more mileage reimbursement. Lets drop down to the paradise known as Detroit for our next shining light of Medicaid fraud- Jacklyn Price. Ms. Price and buddies stole $8.9M from Medicare (so can’t win today, sorry!) using a home health scheme. Over in Brooklyn, Yvette Juarez was picked up on a pretty decent-sized member fraud. She made too much money from her daycare business to be eligible for Medicaid, but falsified income statements in order to get about $72k in benefits. Now on to PA- 4 people operating “Moriarty Consultants” stole as much as $87M from Medicaid by fabricating personal care services claims. It gets good, in addition to boring stuff like faking timesheets, they made up employees and paid kickbacks to bennies to help pull it off (remember, fraud is most effective when you work as a team). Team Moriarty – you win! Your creativity and volume put you over the top; you do not live up to your namesake, however.

Taxpayer tab for this paragraph – about $96M. Work harder- and don’t complain or have bad thoughts about it, or else you’re a meanie!


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 (enjoy the early winter: apparently there are less sun spots right now?) 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 .


Want the Curator News Pack for this week’s Roundup? Medicaid News Curator Volume 2

Here’s the one for the fraud stuff


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