Posted on December 9, 2022 by MM_ADMIN

NY- Medicaid reimbursements inadequate to cover new $17 minimum for home health aides, agencies say

MM Curator summary

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.

[MM Curator Summary]: Home health workers say they are not seeing the money appropriated to up their wages; MCOs say not everybody was supposed to get a raise per the legislation; the legislator who sponsored the bill that funded the increase said it was written poorly; home health agencies cry Big Bad MCOs; and Big Union blames everybody.

Clipped from: https://www.newsday.com/business/home-health-aide-medicaid-minimum-wage-mkef5db1

Home care worker Mildred Garcia-Gallery, right, assists Christine Cipriani at Cipriani’s home in Garden City South. Credit: Newsday/J. Conrad Williams Jr.

An hourly wage increase of $2 designed to help ease the shortage of home care aides is finally in place, but industry players disagree about whether the raise can accomplish its goal without collateral damage.

At stake is home care for Long Island’s growing older population. The region has around 40,140 home care and personal care aides, and is projected to see openings increase by over 64% by 2028, according to the state Department of Labor. Agencies that employ home health aides have said they had trouble attracting workers for the demanding jobs at the previous $15 an hour minimum wage in a market where workers can often make more at Target or Walmart.

In the years prior to the state’s multi-year push to a $15 overall minimum, agency advocates said aides were regularly offered starting pay above minimum wage. But as the minimum wage increased, state-assigned Medicaid reimbursements for many home care agencies did not keep pace, leaving them struggling to keep up.

Home care agencies hailed the move to $17 an hour as a victory when lawmakers included it in the state budget this spring, allocating $7.7 billion to fund it over the next four years.

But now, with the increase in effect since Oct. 1, some agencies say they’re not being reimbursed enough to cover the higher pay. They blame the insurance companies that administer the state Medicaid funds. And they say the raise could end up having the opposite effect, forcing them to reduce workers’ hours and cut staff, or even putting their businesses at risk.

On the other side, the insurance companies charge that some agency owners, already receiving adequate reimbursements, are asking for more just to pad their profits.

A workers’ union says both things are happening. And a legislator who pushed for the higher wage blames poorly crafted language in the state budget for the mess that has threatened the goal — to address the labor shortage and make more caregivers available.

“It is critical that the funds that legislators intended to go to worker pay do exactly that,” said Kathy Febraio, president and chief executive of the New York State Association of Health Care Providers, a trade group representing around 125 home care agencies.

According to an Oct. 5 survey of Febraio’s membership, 75% said they were not getting reimbursement rates high enough to cover increased payroll costs. If the rates they’ve been offered weren’t raised, 29% of respondents said they would reduce staffing levels, with 72% saying they would reduce service hours.

Twelve percent of respondents said they would go out of business.

Representatives for insurance plans, though, reject the assertion that they are withholding reimbursement dollars or providing inadequate reimbursement to agencies.

Insurance plans “have been working diligently to allocate the wage funding provided to them to home care providers which in turn should be spent on workers,” said Eric Linzer, president and chief executive of the New York Health Plan Association, a trade group representing the managed long-term care insurance plans that administer the funds.

“No health plan is paying any provider less than what they need to meet wage, benefit and administrative requirements,” Linzer said. “What’s happening here is you have some providers that already have received enough funding. It kind of begs the question of why do some of them need more, other than to pad profits.”

“I’m very happy that [workers are] getting the increase,” said Nicole Laborde, who owns Ideal Home Care Services in Hauppauge, a provider of home health aides. “However, it’s going to affect a lot of home health care agencies, especially smaller ones.”

Laborde said the insurance providers aren’t providing high enough reimbursement rates to agencies.

“Nobody really looked at how the home care agencies are going to be compensated to be able to afford this increase,” said Laborde, who is also founder and chief executive of Ideal School of Allied Health Care in Hauppauge, which trains health care workers including home aides.

The wage increase is meant to help address a critical labor shortage that’s only expected to worsen as the need for home care aides grows in the coming years.

Aging Baby Boomers have increased the demand for home health services on Long Island as the preference for “aging in place” has grown, said economist Shital Patel with the Labor Department’s Hicksville office. Health care reform has also encouraged the use of home care as an alternative to expensive nursing homes and hospital stays, she said.

There are more than 1,300 licensed or certified home care agencies statewide, according to the New York State Association of Health Care Providers.

Competition for entry level workers from employers like Amazon and Target offering higher hourly wages in the wake of the pandemic has only exacerbated the difficulty in recruiting aides, who provide critical services to seniors and others living at home. Aides not only provide care, but can often become a vital source of companionship, developing close relationships with patients and their families, said aides and care recipients.

Because most patients use Medicaid to cover home care, wages for workers largely rely on reimbursement rates set by managed long-term care plans. While Medicaid is traditionally government health insurance for the most impoverished Americans, it is one of the few ways patients can cover the high cost of home care.

“There are only a few ways to pay for home care,” said Nicole Christensen, patient advocate and president of Care Answered, a Freeport business that helps families navigate the complex world of health care for seniors. Because private health insurance seldom covers home care, she said patients have three options when paying for those services: Paying out of pocket “which becomes very expensive very quickly;” long term care insurance, “which not many people have,” and community-based Medicaid, a form of Medicaid that specifically covers nursing home-level care in the home.

Agencies said they would like to see the state Health Department step in and set a standard reimbursement rate for agencies, which currently negotiate individually with insurance firms.

On average, Febraio said members of her trade organization have been receiving $1.33 per hour in extra reimbursement, half of the $2.66 the group estimated members would need to cover wage increases plus higher payroll taxes and other related costs.

“I believe the Department of Health thought the money would flow through the plans to providers and ultimately to the workers,” Febraio said. “The information that we’re giving to them is making it clear that that’s not happening.”

Linzer, representing the insurance firms, said that when the state set aside funding for reimbursement , they did not intend for every agency to receive a bump of $2 if their existing contracts had higher rates to begin with.

“The state has been very clear that this is not supposed to be a directed payment where everyone gets a $2 increase,” he said. “In instances where you have contracts that exceed the new wage requirements, there will be less of an increase.”

The median annual wage for home health and personal care aides is $31,893 on Long Island, according to state labor data, with experienced aides earning an average of $18.46 an hour.

Sen. Rachel May (D-Syracuse), sponsor of the original fair pay for home care workers legislation that failed to pass but instead was adopted in part in the governor’s budget, said the intent of increasing home care workers’ wages was to retain workers and grow the industry. Now, she said she’s concerned that if agencies aren’t given high enough rates, the wage increases run the risk of making a bad situation worse.

“The fact that the bill didn’t pass and got folded into the budget means a bunch of language we put in the bill to avoid this exact situation didn’t end up in law,” May said. “It’s the opposite of what we’re trying to accomplish here.”

The governor’s office said that due to financial measurements introduced through the Affordable Care Act, insurers handling Medicaid reimbursement cannot keep the money passed through them. Additionally, the state is encouraging home health agencies to report insufficient payments for wage increases to the Health Department.

The department will also “keep reiterating” its guidance on the matter with insurers to ensure compliance, the governor’s office said.

May said she is now working to ensure that taxpayer dollars go to adequately funding agencies so they can pay their employees more. A major structural hurdle is that the reimbursement rates negotiated between insurance companies and agencies are not disclosed to the state, making it more difficult to determine whether insurance plans are paying high enough rates, she said.

“The biggest struggle we have is transparency,” May said. “We don’t know what the terms are of a lot of the contracts.”

Mildred Garcia-Gallery, 53, a consultant, home health aide and activist, said she worked with the New York Caring Majority — a coalition of aides, agencies and elected officials —aides to campaign for higher wages in the industry and reimbursement rates to support them.

After hearing about the state’s plans to adopt a higher wage early this year, she was ecstatic. Now, she said she worries whether higher costs for agencies will mean fewer hours for workers.

“It felt like a slap in the face,” said Garcia-Gallery, who’s worked in home care for 30 years and consults with agencies through her firm Ageless Companions LLC.

She said if agencies are forced to cut hours for workers, then aides won’t be able to earn the overtime pay they need to make ends meet, resulting in picking up work with additional agencies to get by.

“I could find another job but what about these patients? If we exit, what happens?” she said. “It’s a job that I love. But loving it and surviving off of it are two separate things.”

Officials representing unionized aides said they have heard of plans paying rates too low to cover the increased costs, but also said some agencies are more concerned about profit than the wages of their workforce.

“We don’t always agree with the employers and we sometimes think they keep too much of the funding themselves,” said Helen Schaub, political director for 1199SEIU, the union representing 53,000 home care workers in the state, including 5,000 on Long Island. “You have to look agency by agency.”

Schaub said while the wage increase is good for workers, the ultimate problem is that for-profit insurance firms are involved in the Medicaid reimbursement process at all, instead of rates being negotiated directly with the state.

“What has been happening is that the state puts in money at the top and there’s this finger pointing between the employer and plans about who is keeping the money,” she said.

The $17 minimum applies to home health workers on Long Island, in Westchester and in New York City. In other parts of the state, where the minimum for most workers is $13.20, the minimum for aides has gone up to $15.20. Home care workers across the state are scheduled to receive another $1 increase next October.

Winsome Gayle Allen, 58, said the sometimes-challenging work of caring for patients at home has been a personal calling for 40 years.

“The type of work where I feel comfortable is giving my time to elderly people,” said Gayle Allen, of Hollis, Queens, an aide with Fresh Meadows-based Reliance Senior Living Services.

Gayle Allen, who’s been serving patients in New York since moving to the states from Jamaica with her parents at 19, said she’s developed long-lasting relationships with patients and their families.

While she loves what she does, she admits the work can be difficult at times and requires a lot of empathy and patience. Given the demanding hours and low wages, she said workers are in dire need of pay increases above what’s currently being offered.

“I’m not going to beat around the bush…I think we should get a starting pay of $20 an hour,” she said.

Christine Cipriani, 91, of South Garden City said she doesn’t know what she’d do if she didn’t have the support of her regular home care aide Mildred Garcia-Gallery.

“It’s vital for me,” Cipriani said. “My kids are very nice kids, but they have their own stuff to worry about.”

Cipriani said Garcia-Gallery first came into her life three years ago when the aide was looking after her husband until he died a year ago. “She’s like part of my family,” she said.

For Garcia-Gallery, helping Cipriani and other patients fills her with a sense of purpose and comes with emotional rewards.

“I like being needed and having that responsibility,” she said. “We like to do this job because we like to care for people, we love people and we love making people’s lives better or at least trying to.”

Still, she said, while the work “makes me feel important, it doesn’t mean my pay reflects that.”

For Thomas McCarthy, 24, a wheelchair user living in Farmingdale, having access to reliable home care gives him the opportunity to be more independent, he said.

“With just me and my aide helping me out, I’m not so dependent,” said McCarthy, who has Duchenne muscular dystrophy, a condition that progressively weakens muscles over time.

His aide, Marc Bazile, 52 — who lives in McCarthy’s family home every other week to provide round-the-clock care — said the work he does helping others makes him feel good and helps him appreciate the independence he has in his own life.

“I love family. I love to help people,” said Bazile, an aide with Ideal Home Care Services, who commutes from Lancaster, Pennsylvania every other week to assist McCarthy.

Still, Bazile said, pay remains an issue. As an experienced aide already making more than minimum wage, he said he hasn’t seen any impact from the recent $2-an-hour pay increase.

— with Coralie Saint-Louis

Posted on December 9, 2022 by MM_ADMIN

MCOs (NC)- Study: Medicaid transition still facing problems

MM Curator summary

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.

[MM Curator Summary]: Punchline- the challenges are par for the course according to researchers, and the switch actually went really well for the majority of Medicaid members.

Clipped from: https://www.northcarolinahealthnews.org/2022/12/07/study-finds-medicaid-managed-care-transition-still-impacted-by-poor-communication-patient-confusion-and-administrative-burden/

When North Carolina swapped its Medicaid system from a program run by the state to a program run and managed by five insurance companies, researchers at the Urban Institute — a D.C.-based think tank — took note. Among other policies, the organization’s researchers took a look at how transitions to Medicaid managed care impact patients nationwide.

In October, they released a report on North Carolina’s transition so far. They found that the initial transition didn’t lead to disruptions in primary care for most people. Nonetheless, the change still came with plenty of problems: providers didn’t enroll with all of the managed care plans because of the added administrative burden, patients were confused about what exactly the transition meant for them, and some people even ended up with big bills after mistakenly going to out-of-network providers.

“What we found in North Carolina is pretty consistent with experiences in other states that have a transition to Medicaid managed care,” said Urban Institute researcher Eva Allen. “Any changes tend to bring some sort of amount of confusion and challenges for providers and for patients.”

For their analysis, Allen and her colleagues interviewed state Medicaid officials, staff from the insurance plans, provider groups, and advocates and conducted focus groups with Medicaid patients.

The program’s main success is that, according to the report, about 97 percent of people who were auto-enrolled in a plan were able to keep seeing the same primary care provider after the switch to managed care. Officials attributed that success to an algorithm that used previous Medicaid claims to put patients in a plan that their current doctors had joined.

Things didn’t go as smoothly afterward.

Communication issues

Even though the majority of people who were automatically enrolled in a plan were able to keep seeing their primary care doctor, there were still other reasons people might need to switch plans: to keep seeing certain specialists, to make sure all their kids were on the same plan, etc. NC Health News has previously reported that some Medicaid patients who tried to navigate this process said it was excessively complicated and they struggled to find help.

Also, once patients were put on a plan, a care manager from the managed care organization was supposed to reach out to them. But none of the participants in the researchers’ focus groups reported receiving any such communication.

Part of the care management process is supposed to include screening for other unmet needs, such as housing or food.

“Though screening for unmet social needs is reportedly a priority for the state and among plans,” the researchers wrote, “little information was available in spring 2022 about the extent to which and how screenings are being conducted or whether plans and providers are using NCCARE360, an online platform, to connect members to resources.”

The state Department of Health and Human Services said that all of the managed care organizations “are expected” to screen patients for unmet social needs and offer care coordination, but there aren’t standardized rules that determine how the managed care companies do so.

There’s another part of the state’s Medicaid transformation — the Healthy Opportunities Pilot — which is tasked with addressing unmet needs for some Medicaid patients in a handful of rural counties. The administration of that program is different, but it has seen similar problems with the referral process, as NC Health News has previously reported.

More like private insurance than Medicaid

Participants also noted all the ways in which the new system looks and acts much more like private insurance, rather than Medicaid. In the old system, there was no such thing as in-network and out-of-network providers — doctors either took Medicaid, or they didn’t. Also, providers never had to submit requests for prior authorization for certain services, and patients knew which of their medications would be covered at the pharmacy.

After the switch, that all got more complicated. Some patients reported having to pay high costs at the pharmacy for medication they’d been on for years, and others said they had to wait for care that they’d received before without issue because the insurance company hadn’t yet told their doctor if they could do it and get paid for it.

All those changes also contributed to providers’ hesitation to enroll with all the plans. Whereas before, they had one plan to work with — the state Medicaid system — now providers had six. Providers anticipated higher administrative costs and burdens, and many chose to only enroll with some of the plans, all issues NC Health News has previously covered. Some of their fears felt founded, as many had to wait weeks to receive payment due to paperwork issues.

Needing to bill six systems instead of one is an issue that providers repeatedly bemoan. DHHS said it anticipated this problem and that the managed care companies have created a committee “made up of providers and plans who focus on reducing the administrative burdens on providers when working with so many plans.”

The administrative burden is something that almost always arises during the transition to managed care. “Unfortunately,” Allen said, “I am really not aware of any good examples of other states where the state was able to figure out how to make this a better system. It is inherently challenging.”

Incorrectly switching from Medicaid direct to managed care plans

While all of those issues added up to significant burdens for patients and providers, one of the largest single issues the researchers document is how around 7,500 people with significant mental health needs moved onto managed care plans, even though they shouldn’t have. These people were supposed to stay on the state-run Medicaid program until tailored plans aimed at people with significant behavioral health issues roll out (now slated for April 2023).

Once those people moved onto the managed care plans, they lost many of the services they needed and the state had to switch them back. What confused researchers and advocates was why these patients were even offered the option to switch when it meant losing access to the care they needed.

“It’s puzzling to me that the state provided this as an option when it was not in the best interest of the beneficiary,” Allen said.

Medicaid patients in general have questioned who this new system benefits. In the focus groups “some participants reported that with health plans they have a new worry that services they or their children need will be denied.

“Some wondered why the state decided to implement a more complex system when Medicaid Direct was working well in their experience,” the researchers wrote.

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Study finds Medicaid managed care transition still impacted by poor communication, patient confusion and administrative burden

by Clarissa Donnelly-DeRoven, North Carolina Health News
December 7, 2022

Posted on December 9, 2022 by MM_ADMIN

FWA (MA)- Two Individuals Charged With Defrauding MassHealth by Billing for Services Not Provided

MM Curator summary

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.

[MM Curator Summary]: Parisella and Martel used false time sheets for personal care attendant and applied behavioral therapy services to the same relative.

Clipped from: https://www.mass.gov/news/two-individuals-charged-with-defrauding-masshealth-by-billing-for-services-not-provided

SALEM — Two individuals have been charged in connection with a scheme to fraudulently bill MassHealth, the state Medicaid program, for personal care attendant (PCA) and applied behavioral analysis (ABA) services that were never provided, Attorney General Maura Healey announced today.

Jessica Parisella, 42, of Danvers, was indicted Monday by an Essex County Grand Jury on charges of Medicaid False Claims and Larceny over $1,200. Board Certified Behavior Analyst and Licensed Mental Health Counselor Donald Martel, 67, of Georgetown, was also indicted on charges of Medicaid False Claims and Larceny over $1,200. The two defendants are set to be arraigned on January 24 in Essex Superior Court.

The MassHealth PCA program helps people with chronic or long-term disabilities live independently in the community by providing medically necessary physical assistance with personal care needs. Through the consumer-driven MassHealth PCA program, eligible MassHealth members employ PCAs to assist them with their activities of daily living. These services are paid for by MassHealth through a fiscal intermediary.

ABA services are prescribed therapies provided to people with Autism Spectrum Disorder. MassHealth covers ABA therapy to children under age 21; the treatments include professional, counseling, and guidance services that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual.

The AG’s Office alleges that both defendants defrauded MassHealth in a scheme related to Parisella’s relative, a MassHealth member. Parisella was indicted for stealing from MassHealth by submitting fraudulent PCA timesheets, as the surrogate for her relative. Martel was indicted for defrauding MassHealth by submitting fraudulent claims indicating he had provided ABA services to Parisella’s relative. At the time of the alleged fraudulent billing, Parisella’s relative was inpatient at a hospital or incarcerated, and thus unable to receive MassHealth services.

The AG’s Office began its investigation into Martel after a referral from the Massachusetts Executive Office of Health and Human Services.

The AG’s investigation and indictments follow years of efforts by AG Healey’s Medicaid Fraud Division to combat fraud and misconduct in the PCA program. In addition to securing indictments against seven individuals in a coordinated criminal sweep of fraud and abuse in the state’s PCA program in October 2020, the Division indicted a New Bedford man in July 2021 who allegedly defrauded the program by falsely billing for services he did not receive. In March 2022, four individuals were charged with a scheme to falsely bill the PCA program for services that conflicted with outside employment. In June and September 2022, a Medford man and Lowell man were found guilty and sentenced to jail in separate cases for defrauding MassHealth for PCA services not rendered. Earlier this week, the Division announced charges against two defendants for fraudulent billing for PCA services and sex-related crimes against PCAs.

This case is being investigated and prosecuted by Assistant Attorney General William Champlin and Senior Healthcare Fraud Investigator Heather Dwyer of the AG’s Medicaid Fraud Division. MassHealth, Massachusetts Behavioral Health Partnership, Tempus Unlimited, and the Essex County Sheriff’s Department provided substantial assistance with the investigation.

The Massachusetts Medicaid Fraud Division receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $5,542,963 for Federal fiscal year 2023. The remaining 25 percent, totaling $1,847,641 for FY 2023, is funded by the Commonwealth of Massachusetts.

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Posted on December 9, 2022 by MM_ADMIN

FWA (NJ)- Opioid Abuse Treatment Facility to Pay $3.15 Million for Kickback Violations, Obstructing Federal Audit, and False Claims Submitted to Government Insurance Programs

MM Curator summary

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.

[MM Curator Summary]: 2 companies worked together to maximize reimbursement for methadone mixing services.

Clipped from: https://www.justice.gov/usao-nj/pr/opioid-abuse-treatment-facility-pay-315-million-kickback-violations-obstructing-federal

CAMDEN, N.J. – An opioid abuse treatment facility in Camden will pay a total of $3.15 million to resolve criminal and civil claims that it caused kickbacks, obstructed a federal audit, and fraudulently billed Medicaid, Attorney for the United States Vikas Khanna announced today.

Camden Treatment Associates LLC (CTA) agreed to pay $1.5 million in criminal penalties to resolve allegations that it violated the federal Anti-Kickback Statute and obstructed a Medicaid audit. As part of the resolution, a criminal information was filed on December 2, 2022 in Camden federal court charging CTA with this conduct. CTA entered into a three-year deferred prosecution agreement (DPA) that requires it to abide by certain measures to avoid conviction. CTA also entered into a civil settlement agreement to pay $1.65 million to the United States to resolve claims that it violated the federal False Claims Act by submitting fraudulent claims to Medicaid.

Criminal Resolution

According to CTA’s admissions in the DPA:

Between 2009 and 2015, CTA and a second company were owned and managed by related parties. CTA had a kickback relationship with the second company in which CTA ordered all of its methadone mixing services from the second company and paid it more than $125,300 for those services. This arrangement resulted in kickbacks being paid because the second company paid the profits it made on CTA’s orders of methadone mixing to the related parties who owned and managed both companies. As a result, CTA was induced to order services from the second company and to have CTA patients receive treatment using methadone mixed only by that company. CTA received more than $2.78 million from Medicaid for methadone administration services.

In a separate criminal scheme, CTA obstructed a Medicaid contractor’s 2016 audit of CTA’s claims for payment. CTA submitted falsified materials to the auditor purporting to justify its claims to Medicaid. Specifically, CTA added patient and counselor signatures to patient files, altered names of counselors listed as providing services, added credentials for staff listed as performing services, added sign-off dates for services and, in some instances, submitted entire patient notes to files to justify services rendered. Metadata from CTA’s electronic patient software program revealed that CTA employed these fraudulent means.

Civil Resolution

The settlement resolves the civil allegations that CTA submitted false claims to Medicaid stemming from the kickback relationship with the methadone mixing company described above. The settlement further resolves allegations that between 2013 and 2016, CTA failed to comply with certain federal and state regulations governing substance abuse treatment facilities. Specifically, CTA allegedly failed to maintain proper supervision and staffing at its facility. Instead, CTA typically used non-credentialed “counselor interns” to perform services at the facility and did not have sufficient licensed staff to properly supervise the interns. Consequently, CTA’s claims submitted to Medicaid for payment, which were contingent on CTA’s certified compliance with these regulations, were false.

The claims settled by this agreement are allegations only, and there has been no determination of liability.

Compliance Obligations

As part of the DPA, CTA is required to adopt several compliance measures, including:

have an effective compliance program, including enhanced compliance policies and annual compliance training regarding federal health care laws;

retain an independent health care compliance consulting firm specializing in substance abuse disorder facilities to conduct a comprehensive review of its compliance program and to make improvement recommendations;

create an independent board of advisors to oversee company compliance relating to federal health care laws;

have a chief compliance officer to oversee compliance-related functions at the company;

annually certify that its compliance program is effective; and

provide written reports to the United States every six months over a three-year period detailing its progress in developing and enhancing its compliance program.

Attorney for the United States Khanna credited agents of the U.S. Department of Health and Human Services Office of Inspector General, under the direction of Acting Special Agent in Charge Susan Frisco, with the investigation and prosecution of the case. He also thanked the FBI Health Care Fraud Unit Data Analysis Response Team at FBI Headquarters in Washington, D.C., under the direction of Special Agent Greg Heeb; IRS-Criminal Investigation, under the direction of Special Agent in Charge Tammy Tomlins in Newark; and the FBI’s South Jersey Resident Agency, under the direction of Special Agent in Charge Jacqueline Maguire in Philadelphia, for their assistance with the case.

The criminal case was prosecuted by Acting Chief of the Health Care Fraud Unit Christina O. Hud, Chief of the Opioid Abuse Prevention and Enforcement Unit R. David Walk, Jr., and Assistant U.S. Attorney Diana V. Carrig of the Criminal Division in Camden. The civil case was prosecuted by Assistant U.S. Attorney Kruti Dharia of the Opioid Abuse Prevention and Enforcement Unit and Assistant U.S. Attorney Andrew A. Caffrey III of the District of Massachusetts and formerly of the District of New Jersey.

Posted on December 9, 2022 by MM_ADMIN

FWA (NC)- Charlotte woman facing federal charges for Medicaid kickback scheme involving at-risk youth

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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.

[MM Curator Summary]: Bree’Anna Harris et al used foster kids for the billing IDs to steal $4M from NC Medicaid in a drug testing scam.

Clipped from: https://www.wbtv.com/2022/12/02/charlotte-woman-facing-federal-charges-medicaid-kickback-scheme-involving-at-risk-youth/

Bree’Anna Harris has agreed to plead guilty.

CHARLOTTE, N.C. (WBTV) – A Charlotte woman is facing federal charges for operating what’s described as a Medicaid fraud and kickback scheme in Mecklenburg County.

Newly unsealed court documents show Bree’Anna Harris is accused of stealing personal information from at-risk youth to get illegal kickbacks.

Federal prosecutors say she worked with drug testing labs that submitted more than $16 million in fraudulent claims to NC Medicaid, for which they received more than $4 million in reimbursements. They also say those labs paid more than $1.5 million in illegal kickbacks to Harris and her co-conspirators.

Two of those co-conspirators, Markeutric Stringfellow and Glenn Pair, were each sentenced to roughly six years in prison in 2021.

Court documents show the scheme started in 2016, when Bree’Anna Harris and others started paying college students to go to high schools and community centers to recruit at-risk youth for after-school and youth mentoring programs.

The programs were called Do It 4 The Hood, or D4H and Motivation Enterprises.

According to records, they sought out children who were Medicaid eligible and required them to submit urine for drug testing.

They then worked with laboratories that would pay kickbacks based on the number of drug tests submitted.

In a plea agreement, Harris’ attorney entered what’s called a Factual Basis, where Harris agreed to verify the information behind these charges as facts.

Harris is charged with conspiracy and money laundering conspiracy.

In one example listed, Harris and her co-conspirators sent representatives to Harding University High School in Charlotte to sign up a 16-year-old for Do It 4 The Hood.

Court documents show the child never participated in any programs, but submitted one urine sample after she signed up.

Harris and the others went on to submit samples under that child’s name using that child’s Medicaid information multiple times.

According to the filing, each time it was submitted, tens of thousands of dollars would go back to Harris’ bank account or an account set up under a company she created called BPolloni.

Another example details similar recruiting at West Mecklenburg High School.

WBTV reached out to CMS for a statement, but a spokesperson declined.

“To say that this situation is unfortunate, is an understatement,” Sabrina Gilchrist, the executive director of Right Moves for Youth, told WBTV.

Right Moves for Youth provides small group mentoring to students in classrooms across CMS and beyond.

“It’s essential that we maintain integrity and that they trust us,” Gilchrist said.

She was not familiar with Do It 4 The Hood, but says a scheme like this highlights the vulnerability of our youth and the importance of connecting students with fully vetted programs.

“Don’t lose hope,” she said. “Yes, be cautious about what you’re involving your children in, but know that for every one organization that is not doing what needs to be done, there are hundreds more that are doing great work in this community.”

WBTV reached out to Harris’ attorney for comment, but did not receive a response as of news time.

Posted on December 9, 2022 by MM_ADMIN

FWA (NY)- Two Individuals Arrested for Pharmacy Health Care Fraud Kickback Schemes

MM Curator summary

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.

[MM Curator Summary]: Huang and Wu paid bribes and kickbacks so they could bill Medicare and Medicaid for unnecessary prescriptions from their NY pharmacies.

Clipped from: https://www.justice.gov/opa/pr/two-individuals-arrested-pharmacy-health-care-fraud-kickback-schemes

Two New York women were arrested today on criminal charges related to their alleged participation in schemes to pay illegal kickbacks and bribes to Medicare beneficiaries and Medicaid recipients for medically unnecessary prescriptions filled by various pharmacies in New York that resulted in more than $10.5 million in total losses to Medicare and Medicaid.

“As alleged, the defendants repeatedly paid illegal bribes and kickbacks to be able to fill medically unnecessary prescriptions at pharmacies in Brooklyn and Queens, costing Medicare and Medicaid millions of dollars,” said Assistant Attorney General Kenneth A. Polite, Jr. of the Justice Department’s Criminal Division. “Together with our partners, the department is committed to tackling these illicit relationships that defraud federal health care programs designed to assist some of our most vulnerable citizens.”

According to court documents and proceedings, Hua Huang, 47, of Fresh Meadows, and Huiling Wu, 40, of Brooklyn, were separately charged by complaint for their roles in schemes to defraud Medicare and Medicaid through the submission of claims for prescription drugs that were induced by illegal health care kickbacks and bribes at three pharmacies in Brooklyn and Queens.

“The payment of kickbacks in Medicare serves only to enrich the complicit parties at the jeopardy of the program’s integrity and the expense of the taxpayers,” said Acting Special Agent in Charge Susan A. Frisco of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “Our agency and law enforcement partners remain strong in our resolution to investigate and pursue individuals who allegedly operate counter to laws protecting federal health care programs.”

Huang was an employee of NY Elm Pharmacy Inc. (NY Elm), located in Flushing. She allegedly referred an individual to a podiatrist who signed prescriptions – including for durable medical equipment and Diclofenac Epolamine – that NY Elm and other entities with common ownership then billed to Medicare and Medicaid. Huang provided the individual with supermarket gift certificates for each prescription brought to the pharmacy and also provided the individual with cash in exchange for the individual’s monthly insurance allowance for over-the-counter products. Federal law enforcement agents executed a search of NY Elm concurrent with Huang’s arrest.

Wu was an owner and employee of 888 Pharmacy Inc. (888 Pharmacy), located in Brooklyn. She allegedly referred an individual to specific podiatrists who signed prescriptions that 888 Pharmacy then billed to Medicare and Medicaid. Wu provided the individual with store credit for each prescription brought to 888 Pharmacy. She also provided the individual with supermarket gift certificates in exchange for the individual’s monthly insurance allowance for over-the-counter products. Federal law enforcement agents executed a search of 888 Pharmacy concurrent with Wu’s arrest. Two additional pharmacies were searched, one in Brooklyn and one in Hawaii.

“The defendants allegedly participated in schemes designed to defraud Medicare and Medicaid through a coordinated system of kickbacks and bribes for unnecessary prescriptions,” said Assistant Director in Charge Michael J. Driscoll of the FBI York Field Office. “The FBI along with our law enforcement partners remain resolute in our efforts to protect government sponsored health care programs designed to aid members of our community in need. Individuals willing to scam these programs will be held accountable for their actions in the criminal justice system.”

If convicted, Huang and Wu each face a maximum penalty of 10 years in prison. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

The HHS-OIG and FBI New York Regional Offices are investigating the case.

Trial Attorney Patrick J. Campbell and Assistant Chief Miriam Glaser Dauermann of the Criminal Division’s Health Care Fraud Strike Force are prosecuting the case.

The Fraud Section leads the Criminal Division’s efforts to combat health care fraud through the Health Care Fraud Strike Force Program. Since March 2007, this program, comprised of 15 strike forces operating in 24 federal districts, has charged more than 4,200 defendants who collectively have billed the Medicare program for more than $19 billion. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at https://www.justice.gov/criminal-fraud/health-care-fraud-unit.

A criminal complaint is merely an allegation. All defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law.

Posted on December 9, 2022 by MM_ADMIN

FWA (CA)- Three Health Care Providers Agree to Pay $22.5 Million for Alleged False Claims to California’s Medicaid Program

MM Curator summary

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.

[MM Curator Summary]: Dignity and Tenet used false billings for “enhanced services” to make it look like they were meeting the required MLR floors.

Clipped from: https://www.justice.gov/opa/pr/three-health-care-providers-agree-pay-225-million-alleged-false-claims-california-s-medicaid

Dignity Health (Dignity), a not-for-profit health system that owns and operates three hospitals and one clinic in Santa Barbara County and San Luis Obispo County, California, and Twin Cities Community Hospital (Twin Cities) and Sierra Vista Regional Medical Center (Sierra Vista), two acute healthcare facility subsidiaries of Tenet Healthcare Corporation operating in San Luis Obispo County, California, have agreed to pay a total of $22.5 million pursuant to two separate settlements to resolve allegations that they violated the federal False Claims Act and the California False Claims Act by causing the submission of false claims to Medi-Cal related to Medicaid Adult Expansion under the Patient Protection and Affordable Care Act (ACA).

Pursuant to the ACA, beginning in January 2014, Medi-Cal was expanded to cover the previously uninsured “Adult Expansion” population – adults between the ages of 19 and 64 without dependent children with annual incomes up to 133% of the federal poverty level. The federal government fully funded the expansion coverage for the first three years of the program. Under contracts with California’s Department of Health Care Services (DHCS), if a California county organized health system (COHS) did not spend at least 85% of the funds it received for the Adult Expansion population on “allowed medical expenses,” the COHS was required to pay back to the state the difference between 85% and what it actually spent. California, in turn, was required to return that amount to the federal government.

The two settlements resolve allegations that Dignity, Twin Cities and Sierra Vista knowingly caused the submission of false claims to Medi-Cal for “Enhanced Services” that Dignity purportedly provided to the Adult Expansion patients of a COHS between Feb. 1, 2015, and June 30, 2016, and that Twin Cities and Sierra Vista purportedly provided to such patients between Jan. 1, 2014, and April 30, 2015. The United States and California alleged that the payments were not “allowed medical expenses” permissible under the contract between DHCS and the COHS; were pre-determined amounts that did not reflect the fair market value of any Enhanced Services provided; and/or the Enhanced Services were duplicative of services already required to be rendered. The United States and California further alleged that the payments were unlawful gifts of public funds in violation of the California Constitution.

As a result of the settlements, Dignity will pay $13.5 million to the United States and $1.5 million to the State of California, and Twin Cities and Sierra Vista will pay $6.75 million to the United States and $750,000 to the State of California.

“When health care providers misuse Medicaid funds, they undermine the integrity of the Medicaid program and waste taxpayer funds,” said Deputy Assistant Attorney General Michael D. Granston of the Justice Department’s Civil Division. “These settlements demonstrate the Department’s continued commitment to prevent providers from inappropriately using Medicaid or other federal health care programs for their own financial gain.”

“These health care providers siphoned critical Medicaid funding for their own gain instead of using it to provide health care services to patients most in need,” said U.S. Attorney Martin Estrada for the Central District of California. “These major settlements demonstrate our commitment to hold accountable health care providers that seek to exploit the Medicaid program and harm the American taxpayer.”

“Every day, Medi-Cal provides support for Californians in need of essential healthcare, and when companies take advantage of this system at the expense of patients, they must be held accountable,” said Attorney General Rob Bonta. “I want to express my gratitude to the U.S. Department of Justice and the U.S. Attorney’s Office in Los Angeles for their extensive efforts throughout the course of this investigation. The California Department of Justice will continue to prosecute corporations that seek to abuse the Medi-Cal system for their own benefit.”

“Bad actors who target and exploit Medicaid for unlawful profit drain the program of much-needed funds intended to support the health and safety of our nation’s individuals who need these resources the most,” stated Special Agent in Charge Timothy B. DeFrancesca of the Department of Health and Human Services. “HHS-OIG readily applies our investigative aptitude to, with our law enforcement partners, pursue providers suspected of defrauding this and other federal health care programs.”

The civil settlements include the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Julio Bordas, the former medical director of the COHS that contracted with Dignity, Twin Cities, and Sierra Vista for the provision of health care services under Medi-Cal. Under the act, a private party can file an action on behalf of the United States and receive a portion of any recovery. The qui tam case is captioned United States and State of California ex rel. Bordas v. Dignity Health and Tenet Healthcare Corporation, et al. (C.D. Cal.). Mr. Bordas will receive $3.9 million as his share of the federal recovery.

The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, the U.S. Attorney’s Office for the Central District of California and the California Department of Justice, with assistance from HHS-OIG and DHCS.

The investigation and resolution of this matter illustrates the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).

Trial Attorneys Mary Beth Hickcox-Howard and Tiffany Ho of the Civil Division’s Commercial Litigation Branch, Fraud Section and Assistant U.S. Attorney Jack D. Ross for the Central District of California handled this case.

The claims resolved by the settlements are allegations only and there has been no determination of liability.

Posted on December 9, 2022 by MM_ADMIN

MCO – Oklahoma Reissues Medicaid Managed Care RFPs, Proposals Are Due February 8, 2023

MM Curator summary

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.

[MM Curator Summary]: Let’s try this again.

Clipped from: https://openminds.com/market-intelligence/news/oklahoma-rereleases-medicaid-managed-care-rfps-proposals-are-due-february-8-2023/

On December 1, 2022, the Oklahoma Health Care Authority (OHCA) reissued a request for proposals (RFP 8070000052) to implement Medicaid managed care for a program to be called SoonerSelect and the SoonerSelect Children’s Specialty Program for youth involved with the foster care and/or juvenile justice systems. The contractors will be responsible for medical, behavioral, and pharmacy coverage. All health plans will be required to provide SoonerSelect members with the same health care services currently offered by SoonerCare (the state’s Medicaid program) but may offer extra benefits to help improve the health of its members. The state intends . . .

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Posted on December 9, 2022 by MM_ADMIN

TX- Non-Medical Home Remediation Study Could Be Game-Changer For Texas Medicaid Patients

MM Curator summary

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.

[MM Curator Summary]: A new report commissioned by the TX legislature supports funding for improving air quality inside asthmatic Medicaid members’ homes.

Clipped from: https://www.reformaustin.org/healthcare/non-medical-home-remediation-study-could-be-game-changer-for-texas-medicaid-patients/

Evidence from a recent national study of Medicaid benefits shows that newly implemented programs utilizing preventative products and services to address respiratory and other health issues resulted in improved outcomes for Medicaid enrollees. The result of using these non-medical programs was that patients had fewer emergency room visits, took fewer sick days, and ultimately saved on the cost of their medical care.

A report prepared by researchers at Episcopal Health Foundation and the Center for Health Care Strategies illustrates how such programs could benefit Medicaid recipients in Texas.

The report is part of 2022 legislative recommendations from the Texas Value-Based Payment and Quality Improvement Advisory Committee, which urges state lawmakers to expand preventative Medicaid programs that cover non-medical drivers of health. They provide a forum to promote public-private, multi-stakeholder collaboration in support of quality improvement and value-based payment initiatives for Medicaid.

The research that led to the report focused on indoor environmental conditions in which people live and work that influence their health and wellness in non-medical programs covered by Medicaid.

They focused on these three areas:

Air quality issues that trigger asthma attacks in homes and offices
How the lack of access to affordable healthy food contributes to overall health issues
And the maintaining of housing quality to aid in positive health outcomes

An example cited in the report describes how an asthma remediation program identified mold in a 12-year-old girl’s home as a primary trigger of her asthma attacks. So, the program paid to remove and replace moldy carpeting.

The results were profound — she suffered fewer asthma attacks, and no absences from school — and a better ability to keep her asthma under control.

According to the Mayo Clinic, many patients suffer from allergic asthma, which not only includes reactions to typical triggers like pollen, dust mites, and pet dander but also mold and mildew, which the non-medical remediation and other air filtration machines greatly reduce.

“This is a game changer that could improve the health and wellness of Texans most in need in an entirely new way,” Barnes said. “We have to change the way we think about health and how we pay for it. The report shows how things could change for the better in Texas,” said Dr. Ann Barnes, a physician, and CEO of Episcopal Health Foundation.

“As a philanthropy, we’ve funded asthma remediation projects and food as medicine programs that have shown great health improvements, but they were limited to patients of a single clinic or area. This report describes a great opportunity for Medicaid in Texas to cover these non-medical programs on a much larger scale across the state with sustainable funding,” Barnes added.

“Medical care makes up about 20% of what determines a person’s health, yet right now we spend almost all health dollars – including Medicaid – treating conditions medically and not preventing disease outside the exam room,” she continued.

The Centers for Disease Control reviews of similar nationwide asthma remediation showed that for every $1 invested, projects returned anywhere from $5 to $14 in overall savings.

The report also found that the Center for Medicaid and CHIP Services has approved similar non-medical programs in other states, and it provides new guidance that will outline how states like Texas can use “in lieu of services” authority to pay for programs that cover non-medical approaches to health instead of only covering traditional medical care.

According to AsthmaMD.com, 11 Americans die from asthma every day in the U.S., resulting in more than 4,000 deaths due to asthma each year, many of which are avoidable with proper treatment and care.

And the non-medical care advocated by the study could greatly impact this number if adopted more broadly.

In addition, asthma is indicated as a contributing factor for nearly 7,000 other medical emergency deaths each year.

And the cost of treating asthma is a staggering $18 billion per year, while direct costs account for nearly $10 billion, with hospitalizations being the single largest portion, and indirect costs are $8 billion in lost earnings due to illness or death.

For adults, asthma is the fourth leading cause of work absenteeism resulting in nearly 15 million missed or lost or non-productive work days each year.

And, and chronic disease is the top reason for school absences among children ages 5 to 17, which costs the nation’s students an annual loss of more than 14 million school days per year, roughly eight days per year. It results in more hospitalizations than any other childhood disease.

And these figures do not include the impact on the parents of children with asthma, who also suffer lost work days when their children are forced to stay home due to attacks and other respiratory symptoms.

Other successful non-medical programs cited in the report include medically-tailored meals for those with diabetes and other chronic illnesses, fresh produce prescriptions for low-income families, and health-supporting grocery projects for seniors and pregnant women.

These programs show health improvements such as fewer hospital visits and sick days, and also reduced Medicaid spending on medical care by an average of $220 a month per person.

The report found similar evidence of health and financial benefits in housing-related programs that assist people in getting apartments after leaving mental health facilities. Programs that provide financial assistance for making homes accessible for disabilities, helping people learn how to maintain their housing, and negotiations with landlords also greatly benefit recipients.

Along with showing the benefits of these non-medical programs, the report outlines specific ways that Medicaid, Texas Health and Human Services, and Medicaid-managed care organizations could implement the interventions.

Posted on December 9, 2022 by MM_ADMIN

DeSantis urged to release plan for Florida’s looming Medicaid crisis

MM Curator summary

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.

[MM Curator Summary]: Ronnie is being asked what his plan is.

Clipped from: https://www.tampabay.com/news/health/2022/12/08/desantis-medicaid-looming-crisis-florida-children-uninsured-covid-19-pandemic/

Hundreds of thousands of Florida’s poorest children could lose health insurance next year when the federal government is expected to end expanded Medicaid coverage put in place during the COVID-19 pandemic.

The looming crisis has prompted a coalition of 40 Florida nonprofits, health organizations and child advocacy groups to sign a letter sent Wednesday to Gov. Ron DeSantis, urging the state to release its plans for managing the transition.

The number of Floridians relying on the federal program that provides medical coverage for individuals with disabilities and very low-income families and children rose by 1.7 million during the public health emergency to 5.5 million, roughly one quarter of the state’s population.

That was largely the result of the federal government paying states additional money to keep people covered through the federal program during the pandemic even though they were no longer eligible, according to a study by the Georgetown University Center for Children and Families.

But that money will dry up when the federal government ends the public health emergency declaration, possibly as soon as April.

Florida has yet to publish a plan on how it will deal with Medicaid recipients who are no longer eligible and at risk of losing health coverage. The state also faces the burden of having to recertify the eligibility of its 5.5 million recipients, a potential logjam that could force it to hire hundreds of additional workers.

“The public health emergency unwind will mean a tsunami of coverage loss,” said Alison Yeager, executive director of the Florida Health Justice Project. “We know who’s going to be hit the hardest by this loss — parents, children and young adults, postpartum women and the elderly and disabled.”

Florida Department of Children and Families officials said in a statement released Wednesday that they are working with the Agency for Health Care Administration, community partners and other state agencies to begin an effort to reach out to current Medicaid enrollees, emphasizing the importance of providing current contact information so they can be reached.

“To those groups creating unnecessary panic by insinuating that Florida is not prepared, we can assure you that the department is prepared,” the statement says. “There is a plan in place.”

But Florida has not published its plan as states like North Carolina, Utah and Oklahoma have already done.

The coalition’s letter calls for the state to ensure that qualified Floridians maintain their Medicaid coverage and those who are no longer eligible receive help finding other health insurance such as the marketplace options offered under the Affordable Care Act or KidCare, a subsidized insurance program for children.

It also states Florida should follow the recommendation from the Centers for Medicare & Medicaid Services that states stagger a return to pre-pandemic Medicaid operation over a 12-month period.

Nationwide, the Georgetown study warns that 6.7 million children are at risk of losing coverage, potentially more than doubling the nation’s uninsured rate for children if states do not take steps to keep eligible ones enrolled during the transition.

Florida residents currently covered by Medicaid may be more at risk from the end of the public health emergency than most.

Florida is among just 11 states to not take advantage of an Affordable Care Act provision that provides additional money to expand Medicaid eligibility. Doing so would would make an estimated 900,000 Floridians eligible, or more than 4% of the state’s population. That includes more than 400,000 who earn below the federal poverty level, according to the Florida Policy Institute, a Tallahassee nonprofit.

Staff writer Romy Ellenbogen contributed to this report.