Clay’s Weekly Medicaid RoundUp: Week of October 8th 2018

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-


BUCKEYES TO GET MORE OPTIONS ON OPIOID RECOVERY MEDS- Based on what I am hearing, looks like Ohio may be removing prior auth for more drugs besides just suboxone and generics for buprenorphine and naloxone. If you know more, please dial into the show on Monday and weigh in.


NEW PROJECT TO UP CAID IMMUN RATES- If you’ve been around this Medicaid world a while, chances are you have bumped into the immunization “registries” (glorified excel files in a Medicaid official’s computer, usually). The CDC is funding a new consulting project (Nat’l Academy for State Health Policy got $800k) to figure out how to better integrate this data, encourage providers to submit more of it and close gaps for certain vaccines (i.e. Medicaid rotavirus rates for kids are 12 points lower than commercial).


MORE RUH-ROHS IN THE OH PBM SCANDAL- We will cover this in Monday’s show, so tune in. The gist: turns out one of the reasons Centene’s rx costs were more than other MCOs (all of them got caught up in the spread pricing scandal), is because they used their subsidiary (Envolve) as a sort of middle-middle man to the PBMs.


HOW MANY YEARS IS IT OK TO NOT HAVE A MEDICAID INSPECTOR GENERAL IN A STATE? 4 years is the answer if you’re Kansas. After the top Medicaid oversight spot (over the $3B program- but hey that’s chump change when its those taxpayer chumps funding it, right?) sat empty since 2014, the seat is now being manned (wo-manned, actually) by Sarah Fertig. Congratulations, Sarah!


CONGRATS TO OUR FRIENDS AT WELLCARE- It’s the time of year where we see which MCOs are doing better per NCQA quality ratings, and Wellcare just got high marks in NJ and NY. Congrats!


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. Vicki Chisam of Batesville, AR was charged with her role in a $2M Medicaid fraud (part of the Preferred Family Healthcare mental health scheme we have covered). Chisam was apparently the EHR data manipulation specialist in the crimes. She herself is tied to $589k in pilfery. Lyubov Beylina of Brooklyn (along with 7 other upstanding citizens) was charged with stealing $600k for billing for therapy while on vacation in the Dominican Republic. She also forged signatures of parents of children she was therapy-ing. Joanna Michelle Phillips of Cheyenne, WY was sentenced to 18 months for stealing $58k via false claims. Mercy Ainabe of Houston, TX was sentenced this week for her role in a patient recruitment Medicaid fraud scheme. She and her fellow fraudsters used a home health care front to bill for medically un-necessary services, pay bennies to sign-up and send kickbacks to docs. Total tab – $3.6M (but to Medicare, so she can’t win this week). Epo Onega of Staten Island was popped for using her teaching job to steal $59k with bogus speech therapy claims. Vicki- you win! Hopefully you can re-connect with some of your old workmates once you all get sentenced. Taxpayers – you lost about $7M in this paragraph! Work hard! Somebodies gotta pay for all this fraud (hint- you do, chumps). Are you a Medicaid bennie on a waiting list for a waiver program? Keep waiting! Sorry, we have to make sure we keep paying fraudsters before we open up your slot.

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 (plant mums – they can actually do really well in the ground) and keep running the race (you know who you are).

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Trystero: Otac je poslao Sina da spasi svet. Also – chuir an t-Athair am Mac gus an saoghal a shàbhaladh.