Posted on

FL- County throws lifeline to hospitals drowning in Medicaid

MM Curator summary


Miami is now operating a “provider tax” program to maximize federal dollars for hospital Medicaid revenues.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



Miami-Dade County now has a Medicaid Hospital Directed Payment Program (DPP) to give local hospitals financial relief made necessary by unreimbursed Medicaid costs.
The ordinance by Commissioner René García, unanimously approved Sept. 1, would take effect in ten days. The program would provide financial relief to Miami-Dade hospitals, which incur $524 million in unreimbursed Medicaid costs each year.
Currently, Miami-Dade has nearly 17% of the state’s Medicaid enrollees, a memo from Chief Financial Officer Edward Marquez says.
The DPP is a Medicaid matching program funded through local non-ad valorem special assessments on local hospitals. The revenue generated through this special assessment is placed in a local provider participation trust fund and is matched with federal funds to provide hospitals with supplemental Medicaid reimbursement.
“The passage of this ordinance will ensure that our community’s low-income patients benefit from enhanced healthcare services, and hospitals are able to improve their facilities and patient care through the creation of this program, which ensures Miami-Dade County and its residents receive their fair share of federal Medicaid funding,” said Commissioner García in a press note.
Commissioner Rebeca Sosa expressed similar sentiments at the meeting. “When hospitals face staggering losses, they cannot provide the care necessary for the population, those losses prevent or delay upgrades to facilities and staff, and they can create pressure on public facilities. So, it’s a pleasure to join our senator Rene García and all my other colleagues in this item.”
At the July 8 commission meeting, four representatives from local hospitals spoke in favor of the now-approved ordinance. Gino Santorini, CEO of Mount Sinai, said Medicaid comes at a loss in terms of covering the costs, so “this is an opportunity to unlock some federal funds, which would bring about $300 million down to offset that which will really help to benefit all the hospitals, the employers and the county health in general.”
Dawn Javersack, chief financial officer (CFO) of Nicklaus Children’s Health System, said “seven out of every 10 patients that we see are Medicaid beneficiaries and they represent some of the most vulnerable population… This is really important in terms of the care that’s provided to those patients.”
Sanjay Shetty, president of Steward Health Care North America, and Dawn White, vice president of Government and Community Relations for Baptist Health, also expressed support for the creation of the program.
“I am so pleased that the county commission unanimously supported this innovative mechanism for drawing down more funding to cover the costs of care for our low-income residents,” said Mayor Daniella Levine Cava in a press release. “Our local hospitals treat patients with professionalism and compassion. They deserve our support so they can meet the healthcare needs of Miami-Dade families.”


Clipped from:

Posted on

Georgia Medicaid agency requesting nearly $500 million more in health spending

MM Curator summary


GA budget officials are notifying the Governor that Medicaid spending needs to go up while state employee benefit funds are decreasing.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


The agency that provides health care to about 2 million Georgians is requesting an increase of almost $500 million in its state budget over the next year and a half.

Enrollment growth in Medicaid — the state-federal health care plan for the poor and disabled — and rising usage and costs will continue to put a bigger dent in government coffers, officials said Thursday,

Meanwhile, Lisa Walker, chief financial officer of the Department of Community Health, said the health care plan for more than 650,000 teachers, state employees, retirees and their dependents could see two-thirds of its reserve drained by 2024 as expenses outpace revenue from premiums and government subsidies.

Both have become common scenarios for the government programs that fund health care for about a quarter of the state’s population: Heath care costs continue to rise in Medicaid, and that means a larger infusion of taxpayer money into the system. The State Health Benefit Plan for teachers and state employees is regularly projected to run a shortfall in coming years.

Gov. Brian Kemp last month told state agency directors not to request spending increases in the coming year, but he made exceptions for programs that expected to see a rise in usage and expenditures. As in past years, a vast majority of that increase will be in k-12 schools, colleges and the Department of Community Health, which runs the Medicaid and State Health Benefit Plan programs.

Enrollment in some health plans run by the DCH spiked during the initial months of the COVID-19 pandemic as Georgians lost jobs both during and after the economic shutdown.

At the same time, many of those in the program delayed care due to the fear of infection or other reasons. DCH officials expected Medicaid recipients to return to the doctor for treatment this year as COVID-19 vaccinations became more available.

The federal government pays for the majority of the DCH’s $17 billion budget, although the state also chips in several billion dollars. The DCH’s budget, when including federal funding, is the largest part of the state government’s spending.

The DCH has to ask for a big increase in funding pretty much every year as health costs rise. Walker said the department is requesting $122 million more in the midyear budget — which runs through June 30 — and $359 million more in fiscal 2023, which begins July 1.

The agency’s request now goes to Kemp, who will decide what to include in the budget proposal he will deliver to the General Assembly in January.

Besides presenting the DCH budget proposal, Walker on Thursday gave the agency’s board a briefing on the financial status of the State Health Benefit Plan.

Money for the program comes from employee/retiree premiums and the government.

The Community Health board earlier this month froze premiums for members for the third time in four years.

Walker said expenses outpaced revenue by $89 million last fiscal year and would do so by about $337 million this year.

The program currently has about $3 billion in reserve, but that could fall to $1 billion by the end of fiscal 2024 as losses escalate. The trend could be reversed by higher premiums, increased government subsidies, reduced expenditures or changes in the heath coverage.

The teachers, state employees and retirees on the program keep a close eye on its finances because lawmakers raided the reserve during the Great Recession to help the state balance its books. That led to higher premiums and attempts to change benefits to build back the reserve.

DCH officials have projected massive shortfalls in the past, so teacher groups have expressed skepticism about the estimates.


Clipped from:

Posted on

State funds for Oklahoma Medicaid expansion remain untouched

MM Curator summary


OK now has $164M in a savings account it had planned on using for expansion but doesn’t need to because of enhanced COVID funding from CMS.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


OKLAHOMA CITY (AP) — The $164 million appropriated by the Oklahoma Legislature to pay for the state’s share of Medicaid expansion remains untouched in a state agency savings account, state legislators learned Monday.

Oklahoma Health Care Authority CEO Kevin Corbett told House and Senate members that the agency has used savings generated from the Medicaid expansion, along with enhanced federal COVID-19 relief funds for states, to pay for the expansion so far.

The savings were generated by shifting about 65,000 Oklahomans whose health care costs were previously funded through the state’s Insure Oklahoma plan or other sources to the expanded Medicaid population, where the federal government covers 90% of the costs.


Corbett told lawmakers an estimated 700 to 800 Oklahomans are qualifying each day for health coverage under Medicaid expansion, although he expects that number to slow down in the coming months. As of Monday, Corbett said about 170,000 people have qualified for Medicaid under the expansion. The Health Care Authority has projected about about 215,000 residents would qualify for expanded Medicaid, and Corbett says those projections are likely still accurate.

After a decade of Republican resistance to expansion in Oklahoma, voters narrowly approved a constitutional amendment last year to expand eligibility for benefits. Now, an individual who earns up to $17,796 annually, or $36,588 for a family of four, qualifies for Medicaid health care coverage. By contrast, the median income limit for parents in states that didn’t expand their program is about $8,905 for a family of three, according to the Kaiser Family Foundation.


Clipped from:



Posted on

NY- DiNapoli: Medicaid Billing Errors Cost State More Than $1.5 Billion

MM Curator summary


The latest report shows the state pays claims without required provider ids.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


Patients Potentially Put at Risk by Dept. of Health’s Failure to Ensure Health Care Providers Were Properly Qualified

The state Department of Health (DOH) allowed more than $1.5 billion in improper Medicaid payments over the course of several years due to errors in its billing system and may have exposed patients to unqualified and uncredentialed health care providers, according to three reports released today by State Comptroller Thomas P. DiNapoli.

“Troubling errors like the ones routinely identified by my auditors are extremely costly. They can also put patients at risk,” DiNapoli said. “By not fixing problems with the Department of Health’s eMedNY system and other issues, hundreds of millions of dollars more in taxpayer dollars could be misspent and unqualified providers could continue to treat Medicaid patients. The department must act on our recommendations and address these shortfalls, so Medicaid recipients receive the level of care they deserve, and taxpayers’ dollars are spent effectively.”

For the state fiscal year that ended March 31, 2020, New York’s Medicaid program had approximately 7.3 million recipients and Medicaid claim costs totaled $69.8 billion.

The Affordable Care Act and federal regulations mandate that state Medicaid agencies require all ordering and referring physicians and other professionals providing services through the Medicaid fee-for-service program to be enrolled as participating providers and their National Provider Identifiers (NPIs) to be included on Medicaid claims. This screening and provider enrollment process improves the efficiency of the health care system and helps to reduce fraud and abuse. It also helps to ensure the quality of services and protects public health by validating that providers have the appropriate credentials to provide services and are not prohibited from participating in the Medicaid program by the federal government.

In the first report, DiNapoli’s auditors found that a significant number of claims were paid even though they did not have a proper NPI to ensure the ordering, prescribing, referring, or attending provider was properly qualified or credentialed, creating a risk for patients. Processing weaknesses in eMedNY, the Medicaid claims processing and payment system, allowed $1.5 billion in payments for Medicaid clinic and professional claims without an appropriate NPI.

For example, some claims contained NPIs of providers who were not enrolled in Medicaid, while other claims did not contain an NPI at all.

Auditors also found $57.3 million in payments for pharmacy claims that did not contain an appropriate prescriber NPI and $19.4 million in payments for claims that contained an NPI but, according to regulations, should not be included on Medicaid claims or that should be further reviewed by DOH due to past misconduct.

Auditors recommended DOH:

  • Review the Medicaid payments for claims not containing an appropriate NPI identified by the audit and determine an appropriate course of action.
  • Enhance system controls to prevent improper Medicaid payments for claims not containing an appropriate NPI.

The department’s full response to the findings and recommendations is included in the audit.

A second report found that from Jan. 1, 2015 through Dec. 31, 2019, claims totaling $28.5 million were paid for Medicaid recipients who were reported as discharged from a hospital, but then admitted to a different hospital less than 24 hours later. These claims raise the possibility that the first hospital wrongly recorded a patient’s transfer as a discharge, which is a red flag that the claims are at a high risk of overpayment.

In fact, auditors found nearly half of the claims that they sampled (15 of 31) were incorrectly coded as discharges in the eMedNY system. The result of those errors was overpayment of $252,107, or 55% of the total value of the 31 sampled claims. This high error rate raised concerns about the extent of overpayment in the $28 million of high-risk claims. Auditors also found that DOH has no process to identify and recover such improper Medicaid payments.

Auditors recommended DOH:

  • Develop a process to identify and recover Medicaid overpayments for fee-for-service inpatient claims that have a high risk of incorrect patient status codes such as those identified by the audit.
  • Review the $252,107 in overpayments and recover as appropriate.
  • Review the remaining 2,017 high-risk claims totaling $28 million and recover overpayments as appropriate. Ensure prompt attention is paid to those providers that received the highest amounts of payments.

In their response, department officials agreed with the audit recommendations and said actions will and have been taken. Their response is included in the report.

An audit released in July 2019 identified more than $102.1 million in improper managed care premium payments on behalf of 65,961 recipients who had multiple identification numbers in the eMedNY system. In a follow-up report released today, auditors found DOH made progress addressing the problems identified in the initial audit report and the Office of the Medicaid Inspector General recovered $50.8 million of the $102.1 million identified. Another $51.3 million still needs to be recovered.

Since the 2019 audit, auditors identified another $14.3 million in managed care premium payments for 14,293 potentially inappropriate identification numbers for the period July 1, 2018, to Aug. 31, 2020. According to department officials, many of these cases have been resolved or are currently being reviewed.


Improper Medicaid Payments for Claims Not in Compliance With Ordering, Prescribing, Referring, and Attending Requirements (2019-S-2)

Improper Medicaid Payments for Misclassified Patient Discharges (2020-S-8)

Improper Managed Care Premium Payments for Recipients With Duplicate Client Identification Numbers (2020-F-22)


Clipped from:


Posted on

Florida Medicaid Could Face Hefty Deficits

MM Curator summary


Florida budget analyst release the first look at what the impact of ending the additional 6.2% in pandemic funding.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



The estimates show an anticipated $417 million deficit in Medicaid for the current fiscal year, which will end June 30, and a $1.434 billion deficit in the 2022-23 fiscal year.

Florida’s swelling Medicaid rolls are expected to help create a nearly $1.9 billion deficit in the safety-net health care program over the next 22 months, according to new estimates drawn up by a state panel.

The estimates, posted Friday, show an anticipated $417 million deficit in Medicaid for the current fiscal year, which will end June 30, and a $1.434 billion deficit in the 2022-23 fiscal year.

In 2022-23, economists estimate the state will need to spend $35.4 billion to keep the Medicaid program operating at current levels. During that year, economists project that lawmakers will need an additional $1.1 billion in general revenue to fund the state’s portion of Medicaid, which is jointly financed with the federal government.

Along with facing increased enrollment amid the COVID-19 pandemic, the state will need to boost spending because of an anticipated loss of enhanced federal Medicaid funding.

Congress agreed in March 2020 to beef up the amount it spends on Medicaid by 6.2 percentage points to help states during the pandemic. The more the federal government contributes to the costs of the program, the less the state has to pay.

The Biden administration has extended the increased funding through this calendar year, but state economists did not plan on any of the additional funding beyond Dec. 31.

Economists assumed an average 1 percent rate increase in payments to Medicaid long-term care plans and an average 3.6 percent increase in payments to Medicaid managed “medical assistance” plans, effective Oct. 1.

Managed medical assistance plans provide managed care to the broadest group of Medicaid beneficiaries.

The new forecast came after recent estimates that more than 5 million residents will be enrolled in Medicaid between now and June 30.


Clipped from:

Posted on

Ambulance carveout is latest Illinois Medicaid managed care battleground

MM Curator summary


Ambulance providers are lobbying to go back to fee for service payment, but advocates oppose the move saying it will be more difficult to ensure quality member outcomes.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



Multiple ambulances are housed at the LeRoy Emergency Ambulance shed, pictured here Friday.


SPRINGFIELD — Stakeholders are calling on Gov. J.B. Pritzker to sign a bill that passed the General Assembly unanimously and would remove non-emergency ambulance services from the state’s Medicaid managed care program in favor of a fee-for-service model.

While an association group representing ambulance services says House Bill 684 is needed to counter arbitrary denials of claims by private insurers, the governor’s office and the state agency that oversees Medicaid expressed “serious concerns for patient safety and cost” as Pritzker continues to review the bill.

While the bill is a targeted carveout of ambulance services from the state’s Medicaid managed care program, or the privatization of Medicaid, it marks the latest catalyst for debate over the effectiveness of that program which was greatly expanded in 2017 under former Gov. Bruce Rauner.


Chris Vandenberg, president of the Illinois State Ambulance Association, said in a phone call Monday the bill was in response to the “arbitrary” denial of ambulance claims by Medicaid managed care organizations, or MCOs.

MCOs are private insurance companies that contract with the state to manage the care of individuals enrolled in Medicaid. Among other things, that involves working with patients to make sure they receive routine exams and preventive care, and coordinating services provided by their primary physicians and other specialists.

Vandenberg said that leads to MCOs padding profits through denial of claims.

“Since managed care began in Illinois, it’s been a struggle,” Vandenberg said. “So, we have EMTs and paramedics that are working, trying to transport patients, and really, we’re not able to get any of this reimbursement. …And so it’s really impacted the ability to attract and retain EMTs and paramedics, and really it’s causing a serious impact to Medicaid beneficiaries in that they’re not able to find transport as easily as they used to.”

Putting ambulances back in the fee-for-service system would allow providers to submit claims directly to the state Department of Healthcare and Family Services, which Vandenberg said would provide predictability and certainty to the billing process.

Jamie Munks, a spokesperson for HFS, said in a statement the department “remains strongly opposed” to the ambulance carveout, “because it has the potential to negatively affect the quality of service, create longer wait times for medical transports and payment delays for providers, and could create confusion for customers and providers.”

They protect and serve often at minimum wage or no pay at all.


Munks said about $3 million of potential lost revenue due to the state’s tax on MCOs which generates greater federal reimbursement resulting in hundreds of millions of dollars in revenue annually. She also noted unspecified “administrative costs” in switching ambulances back to fee-for-service.

If Pritzker doesn’t act on the bill by the end of the week, it would become law even without his signature. If he vetoes it, lawmakers would be able to override the action with a three-fifths majority when they meet for the veto session this fall.

Pritzker spokeswoman Jordan Abudayyeh said in a statement the governor “will take the appropriate action” before this weekend’s deadline, but “the administration is concerned that this legislation has the potential to disrupt care and reduce the quality of provided services to some of the most vulnerable Illinoisans.”

Specifically, the governor’s office said a Medicaid enrollee needing a non-emergency ambulance ride can currently contact their MCO and be connected with an ambulance transport that’s contractually obligated to respond “in a timely fashion.”

The administration fears if the governor signs the bill, “a consumer will be forced to use the vendor contracted with by the fee-for-services program — a vendor that is not contractually bound to provide timely services.”

“Consumers would be forced into the uncertain position of not knowing which of their health care services are covered by their MCO, and whether they will be able to secure transport in a timely fashion,” Abudayyeh said in the statement. “During the COVID-19 pandemic, the Department of Healthcare and Family Services received consumer complaints regarding the difficulty of securing transport from their fee-for-service vendors to get to non-emergency health care services like check-ups and dialysis.”

Advocates for the bill, including Rep. Will Davis, D-Homewood, who is one of its chief co-sponsors, argued the current MCO structure is what’s threatening response times.

Davis said private ambulance companies often handle the 911 calls for communities that are underserved medically. While companies contracting with those municipalities are already on the fee-for-service structure for emergency services due to changes made in April, payment uncertainty for other transportation services those providers render could affect staffing levels, Davis said.

“It’s not just, you know, the providers trying to get paid,” Davis said. “Their ability to receive resources helps their ability to keep their staffing levels up so they can bring down response times when people call 911. So there’s the staffing aspect of it, there’s the idea of making sure that they can provide services to underserved communities.”

Representatives of the Ambulance Association said an early amendment to HB 684 removed non-ambulance medical transports in an effort to address transportation concerns. The current bill is simply a way to “get paid for the services provided,” which they’ll still be obligated to provide under a fee-for-service system.

Samantha Olds Frey, CEO of the Illinois Association of Medicaid Health Plans, cited concerns similar to Pritzker’s about how the bill “impacts our most vulnerable members that need non-emergency ambulances for routine care such as dialysis treatments, doctor’s appointments, or scheduled hospital trips.”

She noted MCOs can offer higher reimbursement rates than HFS can for such a transportation service, so moving it back to a fee-for-service plan could further jeopardize those Medicaid enrollees. While MCOs have care coordinators that make follow-up calls to transporters to connect a customer to a service, HFS does not, she added.

“IAMHP met with the industry during the legislative session to try and find a solution that doesn’t jeopardize the care our members receive,” she said. “The ambulance industry refused to come to the table in good faith. However, we are still willing to understand what the systematic issue is and work toward a solution.”

Davis, meanwhile, said concerns over “arbitrary” claim denials from MCOs are nothing new or unique to the ambulance industry.

That’s why, as part of a health care reform backed by the Illinois Legislative Black Caucus earlier this year, lawmakers created a Managed Care Oversight Commission to, according to Davis, “really dive deep into if we’re going to continue to have an MCO structure – which, you know, some really don’t want – that we can have more oversight and input into how they operate versus kind of the autonomy that they enjoy right now.”

While Davis said HFS has “abdicated” its oversight role of MCOs, Munks said for over two years the agency has been “holding frequent meetings with providers and health plans, a forum to bring everyone together to resolve issues.”

She said HFS put in place a “claims clearinghouse” creating greater transparency into claim denials, “allowing the department to have better oversight of certain billing issues.”

She said claim denial rates for non-emergency ambulance services within the fee-for-service program are 40 percent, while MCO denial rates are between 10 and 15 percent, although the Ambulance Association disputed that claim, saying the denials it experiences are through MCOs.

As well, while HFS cited a billing complaint portal that has received only four claims in more than 17 months, the Ambulance Association dismissed that portal as “another way to give the providers the runaround.”


Clipped from:

Posted on

Texas Wins Preliminary Victory Against Biden Administration in Medicaid Lawsuit

MM Curator summary


A federal judge has delayed the termination by CMS of the approved DSRIP waiver.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



The impending cancelation of a Medicaid waiver that funds certain instances of uncompensated health care has been paused by a preliminary injunction from the U.S. District Court for the Eastern District of Texas.

The court denied the federal government’s motion to dismiss and approved Texas’ request for a preliminary stay on the waiver cancelation.

Back in April, the Department of Health and Human Services (HHS) announced it had retroactively denied Texas’ Section 1115 waiver under Medicaid. The waiver was applied for and approved by the Trump administration’s HHS and Centers for Medicare & Medicaid Services.

The waiver allows certain categories of uncompensated care to be paid for by the federal government without expanding the welfare program under Obamacare — that would expand the qualifications for coverage under the law.

Without it, Texas hospitals and other health care facilities would find themselves on the hook for billions of dollars that the patients cannot pay for themselves.

Biden’s HHS denied Texas’ approved waiver under the justification that the state had not adequately demonstrated its urgent necessity to skip the typical public notice requirements before approval. Texas had obtained an exemption from those requirements by the Trump administration’s HHS due to the pandemic.

While not part of its official ruling, many in the state on both sides of the political aisle took the denial as a warning shot from the federal government over Texas’ refusal thus far to expand Medicaid.

Texas Attorney General Ken Paxton sued Biden’s HHS director, Chiquita Brooks-LaSure, over the retroactive cancelation. Multiple Texas Republican congressmen joined the suit with the Texas Public Policy Foundation filing an amicus brief on their behalf.

After the injunction, Paxton said, “This deplorable attempt to force our state into expanding Medicaid — the Biden Administration’s ultimate goal — was illegal, and we will continue to fight against every political ploy this Administration throws at us.”

In its ruling, the court said the waiver’s recission has resulted in “[t]urmoil in the State’s Medicaid program.”

A final decision on the case must now be issued and the court will consider the case in full. The Texas Eastern District Court may not be the case’s final stop, either. Whichever way the district court rules, it will likely be appealed by the losing side.

And while this occurs, Texas’ health care industry will rush to cobble together a contingency plan. Texas’ current 10-year waiver expires in September of 2022 and the state would have to expedite a new application should the courts ultimately rule with the federal government.

Clipped from:

Posted on

TMC leaving Medicaid provider tax pool

MM Curator summary


The exit of a major health system from the MO provider tax scheme threatens to weaken the overall success of the arrangement.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


Truman Medical Centers in Kansas City will stop contributing to a financial pooling arrangement that helps maintain political support for a tax that pumps hundreds of millions of dollars into Missouri’s Medicaid program every year. 


The move, which lawmakers began learning about last week, has raised concerns that other providers could follow Truman’s lead — and could ultimately doom the provider tax and the funding it has provided the state for nearly three decades. 

The provider taxes were first enacted in 1992, but a bitter political fight over contraceptive coverage and Planned Parenthood pushed an extension of the taxes into a special legislative session in late June. House Budget Committee Chairman Cody Smith, R-Carthage, who guided the bill through the House, said the pooling arrangement has helped maintain support for the taxes from hospitals that do not serve a large number of Medicaid clients. 

Truman’s decision “is a big blow to the concept, I would think, as they are the largest Medicaid provider,” Smith said. 

TMC has two campuses – one at Hospital Hill in Kansas City and the Lakewood campus, which is a major health-care provider in Eastern Jackson County.

Pulling out of the pool wasn’t an easy decision, Keith King, spokesman for Truman Medical Centers, wrote in an email to The Independent. But he said it is necessary for the hospital’s financial stability.  

“As a safety-net hospital and largest single provider of uncompensated care in our region, Truman Medical Centers/University Health operates on a lower operating margin than most Missouri hospitals,” King wrote. 

The special session extended the provider taxes through 2024. 

Hospitals pay a tax of about 5.75 percent on patient revenues that produces about $1.7 billion annually to support the Medicaid program. Called the federal reimbursement allowance, or FRA, the money finances payments for hospital care and other services provided by Medicaid. 

There are similar taxes on nursing homes, pharmacies and ambulance services. 

For hospitals like Truman that serve a large Medicaid clientele, the tax is paid by deducting what is owed from Medicaid payments. Hospitals that have a limited number of Medicaid patients remit cash to the state. 

The pool is a voluntary arrangement managed by the Missouri Hospital Association. Participating hospitals that receive more in Medicaid payments than they pay in FRA taxes contribute to the pool and hospitals that pay money to the state receive funds to offset the taxes. 

The pool handles about $80 million annually, said Dave Dillon, spokesman for the association. 

Hospitals that serve a significant number of uninsured may gain more financially by walking away,” Dillon wrote in an email. “That’s why we work so hard to maintain the pooling arrangement — because it levels the playing field between potential winners and losers in the FRA, and keeps everyone in the tent.” 

SSM Health, which operates nine hospitals in Missouri, pulled out of the pooling arrangement during 2019, when it was enduring financial stress that led it to put three hospitals up for sale. 

The action by Truman Medical Centers comes as the state is imposing cuts on hospital payments. Gov. Mike Parson vetoed a $50 million appropriation intended to offset cuts to payments for outpatient services, and the hospital association is suing over plans to cut payments for inpatient services. 

The move to managed care, outpatient fee schedules and other factors have destabilized hospitals’ 30-year relationship with the state in the FRA,” Dillon wrote in an emaicl. “Like the game Jenga, the more parts of the structure that are removed, the less stable the whole platform.” 

Neither Truman nor the hospital association would say how much Truman contributes to the pool.  

“But here’s the bottom line: This is a tough year all around, and we’ve been looking at every expense to see what we can cut to potentially meet that small margin we talked about earlier,” King wrote in the email. “These kind of cuts are never easy, but we make them to ensure we can continue to take care of our patients at the level they deserve.” 

The full impact of Truman’s withdrawal from the pool may not be known until the FRA is up for renewal again in 2024. Support from providers for the taxes is vital to the regular passage of extensions. 

“This is about goodwill, it is about having a wider view of this program,” Dillon said in an interview. “It is what underpins the kind of collaborations necessary to do the FRA.” 

Rudi Keller covers the state budget, energy and the legislature. He’s spent 22 of his 30 years in journalism covering Missouri government and politics, most recently as the news editor of the Columbia Daily Tribune. Keller has won awards for spot news and investigative reporting. 


Clipped from:

Posted on

Georgia in line to recover $500 million in Medicaid overpayments

MM Curator summary


GA is completing its effort to recover managed care funds not spent during the pandemic.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



Georgia is in line to recover $500 million from state Medicaid insurers for overpayments in 2020 and 2021, according to an insurance industry official who represents the companies.

Special Photo: Georgia Health News

ATLANTA — Georgia is in line to recover $500 million from state Medicaid insurers for overpayments in 2020 and 2021, according to an insurance industry official who represents the companies.

The half-billion-dollar payout will come from two separate Medicaid recoveries, Jesse Weathington, the executive director of the Georgia Quality Healthcare Association, said. Due to the federal role in financing Medicaid, much of the returned money would likely go to the U.S. government.

The insurers were told the reduction was due to many Medicaid patients skipping medical care during the COVID-19 pandemic, along with other adjustments, Weathington said.

“It was surprising in terms of timing and the amount,” Weathington said. He added that the three Medicaid insurers were not given detailed breakdowns of how the state actuary arrived at the numbers.

The Georgia Medicaid insurers – Peach State, Amerigroup and CareSource – are paid a per-member, per-month rate to care for Medicaid members. These insurers continued to receive those payments from Medicaid while there was a drop-off in patient visits.

The repayments are known as clawbacks: When an organization believes it has overpaid for services, it takes steps to get the money back.

“Clawbacks mean people did not get health care,” Laura Colbert, executive director of Georgians for a Healthy Future, a consumer advocacy group, said. “Essentially, people may have missed services they needed last year. That’s no fault of the [Medicaid insurers] because we saw that happen across the board, regardless of the type of insurance. The state still has a right to address that based on their contract.”

The Department of Community Health, which runs Medicaid in the state, did not respond to GHN’s requests for comment.

The $202 million retrospective rate adjustment for 2020 is now awaiting approval from the federal Centers for Medicare & Medicaid Services, Weathington said. Another $300 million mid-year adjustment for 2021 is currently under negotiation, he added.

Medicaid, jointly financed by the federal government and individual state governments, covers low-income and disabled residents. Georgia pays the Medicaid insurers more than $4 billion each year to provide care to low-income children and other vulnerable populations. The state covers about one-third of those costs, with the feds funding the rest.

It’s unclear how much of the recovered funds will go to the feds and how much to Georgia’s coffers. But if it’s split by the normal funding formula, the state would gain more than $165 million.

The projected $500 million recovery comes after Medicaid insurers posted big profits during 2020, according to the Center for Children and Families at Georgetown University.

Before the pandemic, many states had measures in place to limit the profits that state Medicaid insurers could make on their contracts and ensure taxpayer dollars went to patient care. Georgia was not one of those states, according to the Center on Budget and Policy Priorities.

Other states have adopted or bolstered measures to recover taxpayer dollars that went to Medicaid programs while patients stayed home during the pandemic. There are different ways states can do this.

For example, Virginia directed state Medicaid insurers to increase payments to medical providers.


Two of the Georgia insurers – Peach State and Amerigroup – are owned by publicly traded, for-profit corporations, Centene and Anthem, respectively. Centene last year acquired WellCare, another Medicaid insurer, and closed down its WellCare Medicaid operations in May.

A third Medicaid insurer, CareSource, is a nonprofit company based in Ohio.

Clipped from:

Posted on

Massachusetts Scores 10% Medicaid Rate Hike Through American Rescue Plan Act Funding


MM Curator summary


DME providers will be getting some of the 10% ARP money that MA has requested from CMS.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



BOSTON (July 22, 2021)—The MassHealth Medicaid program is implementing a 10% rate increase for durable medical equipment (DME) claims with dates of service effective July 1, 2021. The broad-based relief applies a 10% increase for all DME and augmentative and alternative communications codes and a 50% increase for labor code K0739, which covers repair or nonroutine service for DME other than oxygen equipment requiring a skilled technician.

“This is a big win when we needed it most,” said Jason Morin, president and CEO of the Home Medical Equipment and Services Association of New England (HOMES). “Between the pandemic impacts and the recent respiratory recall, providers are reeling and struggling to find ways to continue to absorb these rising costs. This action provides much-needed direct relief to the providers of Massachusetts and also shows us that the state’s Medicaid leadership is listening.”

In June, HOMES requested that DME suppliers receive a share of the health care focused relief funds granted to Massachusetts through the American Rescue Plan Act. This request, coupled with HOMES’ long-term efforts to build strong relationships with MassHealth leaders and other healthcare officials, gives suppliers serving Medicaid beneficiaries in the state a better footing to deal with higher product and operational costs related to the pandemic.

“It took a long time to develop, but we currently have an excellent relationship with the state Medicaid program. As a result, they have not only come to understand the value that our industry brings to their beneficiaries but also became provider advocates on a number of issues,” added Morin. “I also can’t overstate how instrumental Laura Williard, David Chandler, and the AAHomecare team have been in helping us to develop materials and resources and provide a national perspective in many of our meetings.”

AAHomecare has worked closely with state and regional association leaders to develop sample letters to request that DME suppliers receive a share of the $195 billion allocated to states to mitigate the fiscal effects of the COVID-19 pandemic on health care providers as well as a temporary 10% increase in federal matching funds for home and community-based services (HCBS). We will share more details on these efforts in an upcoming edition of Payer Relations in Focus.

“DME suppliers deserve a share of this support, and we’re committed to helping state leaders make the strongest possible case for being included in state-directed relief,” said Laura Williard, AAHomecare vice president of payer relations. “Now that the first state has explicitly approved our industry to share in this relief, we have an opportunity to let Medicaid officials in other states know about the precedent Massachusetts has set.”

Read the Massachusetts HHS announcement here.

Clipped from: