Weekly Medicaid RoundUp: Week of December 4th, 2017

Soundtrack for today’s RoundUp pessimist readers-

Soundtrack for optimist readers


LET’S TALK SHOP AT MEDICAID INNOVATIONS 2018 – I will be in Florida again (7th year for me, I think) for the Medicaid Innovations Conference. If you are going, let’s plan on meeting up. Jan 31-Feb 2, 2018. Check it out here- http://bit.ly/2mbKtl1


IN HONOR OF THE TAX BILL MAKING ITS WAY INTO LAW- Whether you believe the “its evil and terrible – the only thing more terrible are the last 5 Republican bills we promised were the most terrible ever” – nonsense about the developing tax plan, it’s a topic of discussion. Maybe not as big a topic as Stuart Smalley this week, but still- taxes are on most people’s mind (at least the 50% of us that pay taxes) this time of year anyway.  So, in honor of taxes (long live King George!): Let’s also look on the spending side. More specifically, the fraudulent spending side.


TO TEE IT UP- The latest GAO report on fraud in Medicare and Medicaid is out this week. You know, the one they put out every year that all of us in the space ignore because it ain’t our money (or whatever reason we use to justify not caring about 10% of the funds meant for these vulnerable members we claim to care so much about just vanishing. Most of my good friends opt for the “but fraud happens in other payer verticals, too” garbage.) This year’s report – out this week – shows $95B lost to improper payments in Medicare and Medicaid. Cue hair-splitting discussion re: fraud vs waste vs improper vs Oh, look a squirrel! GAO is giving CMS credit this year for new investments to fight fraud, notably red-flagging certain provider types, creating a Center for Program Integrity and requiring anti-fraud training. But that’s where the compliment sandwich ends (spoiler- its more of an open faced-sandwich this time). According to GAO, CMS has missed basics like conducting a fraud risk assessment for Care and Caid. And in GAO’s view, this is a big omission. The size and complexity of the 2 programs make this an “Of course there is a huge fraud risk here” issue. Check out the article on this in the twitter feed to make sure and see Kirk Nahra’s comments on anti-fraud data analytics being oversold in the last 20 years. Sobering.



FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. Antoine E. Skaff of Charleston, WV stole $735k from Medicaid for dental services over 7,836 acts of fraud between 2011 and 2016. Salomon Melgen of West Palm Beach, FL is in court over $100M he stole from MediCARE using bogus eye visits and tests. Investigators nabbed him using data showing Melgen seeing 100 patients a day and performing procedures in seconds that should take 10 minutes. Kristina Mirbayeva of Brooklyn lead a huge fraud operation (34 defendants, spanning 14 companies and 100 bank accounts) that sent recruiters into soup kitchens and job centers to get Care and Caid members enticed with $40 kickbacks to go to one of their clinics and get a ton of tests done. In 2 short years this netted the bad guys about $146M. Joseph Korzelius of Tryon, NC was sentenced this week for using his counseling business to pilfer $436k from Medicaid. Mr. Tryon used his side job of elementary school guidance counselor to steal students’ Medicaid numbers and submit false bills. Maxim home health in Massachusetts settled with Medicaid this week over stealing $14M by billing for unnecessary services for elderly members (95,000 claims for services not covered). A new report out from the Louisiana DOH shows $717k in payments for dead members between 2013 and 2017. That’s better than the $1.85M paid for dead folks in 2012/2013. Cynthia Stiger and Jacques Roy of Dallas (along with 5 other defendants) just finished up their trial. These 2 stole $374M from MediCare using their bogus home health company. They made up fake plans of care and then the good doc (Roy) would sign off on them so they could bill. Hard to do a tally this week since there’s some big MediCare ones in there. But the clear winner is Kristina. She showed leadership by inspiring a huge team of defendants to navigate a complex web of deceit! But hey- evil Republicans reduce spending. Tax cuts for the 1% Eat the rich.. #Resist!!


That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (pour some salt on your steps) and keep running the race (you know who you are).


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