Clay’s Weekly Medicaid RoundUp: Week of September 30th, 2019

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-  (read the comments on this one. Will make you smilecry)

AND SO IT BEGINS- Walmart opened its first “super center for healthcare services” in GA a few weeks back. Can you imagine what Medicaid spending will be like once Walmart is an enrolled provider? Will we be getting roll-back pricing on imaging, physician services and lancets? I sure hope so.

KEYSTONE STATE TRYING TO WORK OUT WORK REQUIREMENTS– Despite The Good Guvn’r Wolf’s veto-ing similar bills twice, reps in the PA state house are spinning up another work requirements bill. The main talking point that could get this one legs is from Sen. Martin of Lancaster County –  “This program, last year, grew by over one billion dollars. If it keeps growing at the pace it’s growing, the program is not going to be sustainable.” Mr. Martin, don’t you know Medicaid is different? Every time a Medicaid claim is paid, a Bitcoin is mined in the MMIS subsystem, thus creating new value. Medicaid is actually a money maker, sir. Get with it!

GA TRYING TO MAKE NEMT PERMANENT/ FOR REALS– While some states are relieved they don’t have to shell out millions for NEMT anymore (as CMS regs will likely make it optional soon), of course the low-informed press paints all this as “rolling back protections.” For those not familiar with NEMT, that’s non-emergency transportation- a benefit that costs $3B+/year. Its important, but also riddled with fraud and often crappy execution. Some states (particularly those with decent public transport) have already gotten approval to not have to pay for it. But I digress (into things like “details” and “balanced information”)- PeachState lawmakers are trying to get a bill that makes it state law to have to pay for it regardless of what the federalis do.

WE PROMISE THE NEXT $8B WILL TRANSFORM IT FOR REAL THIS TIME– NY’s first DSRIP waiver was focused on reducing hospital admissions by 25% (that did not happen). The next big idea being pitched to CMS (you have to have an idea that at least some sucker will buy; you can’t just come out and say the truth that you just need more and more and more Medicaid moula to keep the chaos going) is that the next $8B will move more payments into Value Based Contracts. Keep in mind the first version touted its aggressive move to value based contracts (something like 80% by 2020 I think). Value Based Contracts is now akin to “abracadabra”. Or, more accurately, “open sesame.” Waivers typically go about 5 years at a time (and are never not renewed), so my prediction is this one gets approved and in 2025 we will hear again that same abracadabra (value based contracting) and again open that sesame (another $8B+ spend).

AETNA SAYS NC SCORING SYSTEM UNFAIR- Aetna lost by a tiny percentage of points under the NC managed care RFP scoring system (there are many issues inherent with this procurement approach – hop on one of our monthly webinars to hear about them). But a new thread has emerged in which Aetna is complaining that one of the state scorers lives with a BCBS (a winner) employee. Best I can tell that’s the extent of their “unfairness” argument. And if NC is anything like AL (where I live), you can’t shake a dead cat (or stick or something. I can’t keep up with who is or isn’t offended by which version of that analogy; is that even an analogy? Is anyone really offended by it, anyway? Or do I just assume they are? Is that in itself offensive? Please members of the online outrage/cancel culture let me know in the comments) without hitting a BCBS employee. They are large employers in many states is what I’m saying.

CMS GETS NEW FRAUD TEETH- Its really hard to believe we will ever stop the flagrant fraud in Medicaid, but this is a new blip on the radar. CMS issued a final rule last week that lets them exclude providers in new ways and for longer periods of time. The gist is that docs with affiliations with parties with one or more disclosable events can now be nixed from the Medicaid funding gravy train (all these terms, with the exception of gravy, are defined in the reg here. For a solid gravy recipe, visit here). Under the new reg, docs can be banned from Caid for 10 years for the first offense (its now 3) and 20 years for the second offense.


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.  Joseph Kimble of Longview, TX plead guilty earlier this month to using his company Tiger EMS to steal $750k (via bogus non-necessary ambulance rides). Skip on up to Union City, NJ and we find Alex Fleyshmakher, Reuben Sevumyants, Samual Khaimov and Yana Shtindler getting nabbed for stealing $99M from Care and Caid. What are they charged with? Using their pharmacies to get paid for scripts they never gave to patients and bribing doctors to help out with the scheme. Let’s head south to VA Beach, where we find Udaya Shetty pleading to stealing $460k for double, triple and quadruple booking patients and getting paid for it by Medicaid. Mr. Shetty (a therapist/psychiatrist) would spend about 5 minutes with patients, write a script and then herd the next one in. He then had his staff bill as if he had spent 40 minutes with each. While the total fraud on this one is $460k, Caid got taken for $161k, Care for $169k, TriCare for $72k and BCBS for $62k (kudos to the journalist for separating that out in the story). Keep heading south to Hotlanta, where Diandra Bankhead stole $1.2M of your tax dollars using a home health scheme involving medically fragile children. Her company “Elite Homecare” submitted 5,400 bogus claims to Medicaid. Head up to Balto (still below the Mason-Dixon line, though) to meet Celeste Bland-Guary. Celeste plead guilty to using her counseling business to steal $82K in Medicaid bucks. All things considered, the award this week goes to the Four Caballeros in Union City! We don’t yet know how much of the $99M they stole will turn out to be from Caid, but it will almost certainly end up being more than the other candidates!

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 (it must surely one day rain, mustn’t it?) and keep running the race (you know who you are).

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