Weekly Medicaid RoundUp: Week of September 5th, 2016

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2cz0jxc (this song is so depressing, but the video is important- pay attention to Amber alerts, people!)

Or you can click the one for optimist readers – http://bit.ly/2cyUfVy (Freddie still gives me goose bumps. And I still believe this song at every football game)


DO YOU REMEMBER WHERE YOU WERE WHEN THE TOWERS FELL? This Sunday will be the 15th anniversary of the terrorist attack on the United States that killed 2,996 people and changed the course of history. I was asleep on a couch in the Southside of Birmingham, Alabama. I got woken up with a phone call from my father telling me to turn on the TV. Where were you? Write in in the comments or send me a note. Never forget. Teach your children.

THE INVISIBLE HAND (THE OTHER ONE, NOT ADAM’S SMITH’S)- MA is looking to cap MCO provider payment rates at 105% of FFS rates. Hospitals in MA currently claim they get 76% of the cost of care (then go out of business already and get into something you can make money in, if you’re really taking those types of hits!) under the non-capped setup. The hospitals claim that the cap would bring payments down to 56% of the cost of care.

TOUGH COUPLA WEEKS IF YOU’RE IN THE DIALYSIS SPACE –  A few weeks ago CMS took a shot over the bow (in a well done RFI-way, if you ask me) at how some providers jimmy with insurance for dialysis members to get higher payment rates. This week saw the KY Attorney General Andy Beshear (somebody tell me he’s not the previous Guvn’rs son…) take a shot at Fresenius, saying they promoted a harmful dialysis product to patients.

SAY IT WITH ME: CON-SOL-I-DAY-SHUN- New numbers out this week quantify what we in the space all know: the vast majority of MCO-covered lives are in a handful of plans. Roughly 43% of all Medicaid managed care bennies have a card from one of the top 5 national MCO outfits.

SHOW ME STATE DOES SHOW AND TELL- Telehealth in schools, that is. The Good Guvn’r Nixon signed a law to allow schools to bill Medicaid for teleconferencing physician services for students. The new funding approval is expected to help students with speech / language therapy and behavioral health needs the most. Rural areas have had a particularly hard time getting these types of specialists out to schools.


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. Jesus Villegas of Milford, CT extracted (he’s a dentist) $1.4M in fraudulent payments by using non-credentialed assistants to run up x-ray tabs for MA Medicaid. Great Nursing Care of Reynoldsburg, OH nabbed $4.9M in Medicaid overpayments using less than qualified providers (I see a pattern) and billings for unauthorized services. Owners closed shop upon receipt of the auditor’s letter. Oh, well – what’s another $5M in taxpayer dollars that just vanished into thin air? That’s just a drop in the bucket, nothing to see here. Move along. CVS in MA has agreed to pay Medicaid $800k for being so terrible at monitoring drug seeking behavior for opioid addicts (there was a system that tracked this, but CVS did not give its pharmacists access to it). Mr. Villegas, you win this week’s award. Awesome first name, by the way- but you do it dishonor.

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 (temps are dropping) and keep running the race (you know who you are).


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