Clay’s Weekly Medicaid RoundUp: Week of October 3rd, 2016

Soundtrack for today’s RoundUp pessimist readers-


Or you can click the one for optimist readers –


THE TIMES THEY ARE A’CHANGIN’- CMS and OIG released a joint proposed rule (is that normal?) to update the state MFCU (funny sounding acronym re: state fraud units for those unaware- and yes we all think it sounds dirty when you pronounce it like a word) regs that are basically unchanged since 1978. The changes will align the reg with statute changes as well as with best practices. There’s a good many updates- I recommend one of the summaries from JDSupra and others (check the twitter feed).


CONGRATS TO NE FOR APPROVAL FOR HERITAGE HEALTH- NE has gotten approval from CMS to launch its innovative integrated care approach to managed care. The state already has 80% of bennies in managed care – the new program will now have MCOs running admin for physical health, mental health, and Rx. Heritage Health is set to launch Jan 1.


KS STRUGGLING. STILL STRUGGLING- RoundUp readers and show watchers know we have been talking about the KS backlog since the summer. This week saw a new lawsuit (with a nursing home suing the state on behalf of 21 patients that could get kicked out if their apps don’t get approved and I mean fast) and new concerns expressed by legislators over a new lurking backlog. Seems the initial backlog (which is almost cleared) was actually under-reported by about 12,000 applications. From what I can tell, the 12,000 now in the cue are mostly renewal applications.


TN SAVING BOUCOUP BUCKS WITH EPISODE-BASED PAYMENTS- TN Medicaid moved to episode based payments in 2013 and is now able to report it saved $11M in year 1 with the value vs volume approach. Nice to see its paying off! Congrats to Brooks Daverman and team (check out the April episode of the state spotlight on the website to get a deep dive on the TN model).


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. Philip Esformes of Miami is charged with running a 14-year, $1B Medicaid fraud scheme. Seems he and his father used bribes and kickbacks to increase payouts to their network of nursing homes.  Katia Donnelly, a DME company owner in Huntington, NY plead guilty this week to stealing more than $2M from Medicaid. Francis Kimaru and 2 others running Compassionate Homecare (Worcester,MA) were indicted this week on $800,000 worth of Medicaid fraud charges related to unnecessary services and services not authorized by a physician. Chanda Hall of Baker, LA was sentenced this week for using her home care company (Empowering Care Services, LLC) to steal $1M from LA Medicaid. How did Chanda get caught? When paramedics were sent to the home of a patient who had been supposedly receiving services from Empowering Care, but had been in fact abandoned a while back. Paramedics reported the patient was “severely malnourished and neglected to the point where (her) own fingernails had grown until they were curving around and growing back into the flesh of her palm.” Once patient zero was discovered, the larger fraud was identified. Medicaid fraud has very real consequences for vulnerable patients, people. You can take your “oh, but its just a drop in the bucket” and shove it. Chanda, you’re not the biggest this week, but in the spirit of the upcoming Halloween/Election season, you win on evil factor alone. I pray your jailors take better care of you than you did those entrusted into your care.

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 (make some sort of hay/pumpkin decoration- you know you want to) and keep running the race (you know who you are).


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News that didn’t make it and sources for those that did: twitter @mostlymedicaid*sinugo ng Ama ang Anak upang iligtas ang sanlibutan*