GAO updates challenges for improper Medicare, Medicaid payments

Best listening experience is on Chrome, Firefox or Safari. Subscribe to Federal Drive’s daily audio interviews on Apple Podcasts or PodcastOne.

Somewhere along the line, annual spending for Medicare and Medicaid hit the $1 trillion mark. More than half is Medicaid. Too much of that money goes out as improper payments and the Centers for Medicare and Medicaid Services has been on the Government Accountability Office’s high risk list for a while. Carolyn Yocom, the GAO’s director of health care issues, gave highlights of the latest progress report on Federal Drive with Tom Temin.

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Has refusing Medicaid expansion cost veterans? Candidate is on right track

For years, Democrats in North Carolina have pushed to expand Medicaid, a move they say would help hundreds of thousands of North Carolinians afford health insurance.

JD Wooten, A Democratic candidate for state Senate, added new fuel to the expansion debate when he blasted his opponent, four-term Republican incumbent Sen. Rick Gunn, in a campaign ad.

“My opponent, Rick Gunn, blocked the expansion of Medicaid — costing half a million people health insurance, including at least 23,000 veterans,” Wooten said in a caption posted with the video.

We wondered if Wooten — who is running in North Carolina’s District 24, which includes Alamance County and part of Guilford County — was correct in his estimates. We decided to take a look.

‘Blocked the expansion’

Medicaid provides health insurance to low-income people. North Carolina has participated in the program since 1970 but remains one of 17 states that has not moved to expand it. Medicaid expansion — an action made possible by the federal Affordable Care Act — would give coverage to folks with household incomes below 138 percent of the federal poverty level. As a result, many North Carolinians who do not qualify for the ACA’s health care subsidies or regular Medicaid coverage would be able to escape the so-called coverage gap.

Since his election in 2016, Democratic Gov. Roy Cooper has battled with conservatives in the state’s Republican-led legislature over the issue. There were signs of a bipartisan agreement when Republicans authored a 2017 bill called “Carolina Cares,” but the legislation never got off the ground in committee.

But while some state Republicans have worked toward compromise, Gunn was among many co-sponsors of a 2013 bill that rejected the ACA’s optional Medicaid expansion, clarified the state’s intent not to operate a state-run health benefit exchange and determined that Medicaid eligibility decisions would be made by the state rather than the federal government. The bill was adopted by a vote of 74 to 40 in the state House and 31 to 16 in the state Senate and signed into law by then-Gov. Pat McCrory.

Gunn did not respond to multiple requests for comment, but Republican leaders in the legislature have consistently opposed Medicaid expansion, saying North Carolina’s share of the rising cost of the program would be too expensive. Senate leader Phil Berger called it a “budget-busting” expense, The News & Observer reported in 2017.

‘Half a million people’

The Wooten campaign cited several reports to support the claim that withholding Medicaid expansion was costing half a million North Carolinians health insurance.

Among those were articles from the left-leaning North Carolina Justice Center, the pro-expansion Close the Gap NC and the North Carolina Medical Journal, all of which estimated that the expanded benefit would give new coverage to some 500,000 people.

Most other reports predicted similar results. The U.S. Census Bureau, for example, estimated in 2016 that there are more than 440,000 North Carolinians who are uninsured and earning less than 138 percent of the federal poverty level.

David Anderson, a research associate at Duke University’s Margolis Center for Health Policy, said the actual impact would likely exceed the Census Bureau’s estimate because additional people who are currently insured on ACA exchanges could be expected to transfer to Medicaid if an expansion bill passed.

“The estimate of 500,000 North Carolina residents would be covered by Medicaid is a solid estimate well within consensus, expert opinion,” Anderson said.

Other experts we consulted agreed. “It appears that about a half a million people is close in the estimate,” said Lisa Dubay, senior fellow in the Health Policy Center at the Urban Institute, a left-leaning, Washington-based think tank.

Predictions and estimates vary, but Wooten’s claim does not seem to oversell the impact Medicaid expansion could have. In a 2017 article, North Carolina Health News reported that the number could even exceed 625,000, according to the state’s Medical Care Advising Committee, a collection of health clinic managers, doctors and administrators.

Veterans affected

The Wooten campaign did not say how or where it found its estimate for the impact on veterans, but the number may have come from NC Policy Watch, the news arm of the NC Justice Center, which cited a 2013 study from the Robert Wood Johnson Foundation and the Urban Institute.

According to that study, approximately 23,000 North Carolina veterans would receive Medicaid coverage under an expanded program. Anderson noted, however, that although the estimate resulted from a sound statistical process, it is becoming outdated.

Jennifer Haley, a research associate in the Health Policy Center at the Urban Institute who co-authored the Robert Wood Johnson Foundation study, also directed us to a more recent report issued by the Urban Institute in 2016.

That report estimated that, of the 25,000 veterans projected to be uninsured in North Carolina in 2017, 2,000 would be eligible for but not receiving Medicaid and another 12,000 would fall into the coverage gap, for a total of approximately 14,000 people.

This number is short of Wooten’s 23,000, but Anderson explained that the difference between the two studies’ findings is likely due to sampling error and trend changes.

“The caveat with Medicaid expansion is that current veterans who make between 100 and 138 percent (of the federal poverty level) would be able to switch their insurance to Medicaid or gain coverage,” Anderson said. “There are no good numbers for that. I think it is safe to say that the most recent study gives a floor of 14,000.”

So Wooten’s estimate may be outdated, but it does not seem unreasonable. And his larger point — that a large number of veterans would gain coverage from Medicaid expansion — holds true.

PolitiFact ruling

In the caption of a video posted to Facebook, Wooten said, “My opponent, Rick Gunn, blocked the expansion of Medicaid — costing half a million people health insurance, including at least 23,000 veterans.”

Wooten is mostly correct on the first two charges and close to correct on the third.

Gunn co-sponsored a 2013 bill that rejected Medicaid expansion, so even if he was not solely responsible for blocking expansion, he played a role in it.

Experts agree this is costing approximately 500,000 North Carolinians the chance at receiving health coverage. That would include many veterans, although the exact number is less clear than Wooten suggested. But given the available research, Wooten’s number seems reasonable.

PolitiFact rates this statement Mostly True.

This story was produced by the North Carolina Fact-Checking Project, a partnership of McClatchy Carolinas, the Duke University Reporters’ Lab and PolitiFact. The NC Local News Lab Fund and the International Center for Journalists provide support for the project, which shares fact-checks with newsrooms statewide.

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Child participation in Medicaid, CHIP up from 2013 to 2016

(HealthDay)—From 2013 to 2016 there was an increase in children’s participation in Medicaid and the Children’s Health Insurance Program (CHIP), according to a report published in the August issue of Health Affairs.

Jennifer M. Haley, from the Health Policy Center in Washington D.C., and colleagues used data for 2013 to 2016 to examine uninsurance and eligibility for and participation in Medicaid/CHIP among individuals aged younger than 65 years.

The researchers found that overall, Medicaid/CHIP participation reached 93.7 percent in 2015; programs reached more than 90 percent of their target population of children in all but five states, while in four states, participation was above 97 percent. In every state, participation was lower among parents than children, with participation ranging from 94 percent. On average, participation in 2016 was higher in Affordable Care Act (ACA) expansion versus non-expansion states. The increase in children’s Medicaid/CHIP participation correlated with a 47 percent decrease in the number of eligible but uninsured children, from 3.5 to 1.9 million between 2013 and 2016. In 2016, an estimated 5.7 million adults were eligible for Medicaid but uninsured; 73.6 percent of them were in expansion states.

“Children’s participation in Medicaid/CHIP rose between 2013 and 2016, which suggests that continued policy efforts to improve outreach, enrollment, and retention and the implementation of the ACA’s coverage provisions succeeded in reducing the number of eligible but ,” the authors write.

Explore further:
Nearly 1 million more kids have health coverage after Obamacare

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Owners of assisted living home where worker was murdered convicted of Medicaid fraud

The owners of an Anchorage company that ran assisted living homes for people with disabilities were convicted Thursday of fraudulently billing Medicaid for services that were never provided, bilking state taxpayers of hundreds of thousands of dollars, prosecutors said.

The company, Flamingo Eye LLC, came under scrutiny by state investigators in 2015 after a resident at one of the homes killed his caregiver.

The trial lasted five weeks and included the testimony of a dozen witnesses. On Tuesday, jurors concluded that Flamingo Eye and its owner, Margaret Williams, were guilty of committing a number of crimes, including felony medical assistance fraud, between January 2011 and December 2016.

“The business model was to house vulnerable disabled adults approved for Medicaid-funded care, not provide that care at all or over-report the level of care provided, and fraudulently bill Medicaid,” assistant attorney general Eric Senta wrote in a charging document.

On Nov. 7, 2015, Gilbert Nashookpuk called 911 and told police he strangled, kicked and punched his caregiver, Glenna Wyllie, at a Flamingo Eye home on Viburnum Drive in South Anchorage and hid her body behind a basement freezer. He was sentenced to 60 years in prison about two and a half years later.

At the time, the company was operating a number of assisted living homes for people with disabilities in the Anchorage area. The homes housed between 10 and 15 people at any given time, Senta wrote in the charges.

While investigating the business after the slaying, an investigator “discovered discrepancies and impossibilities on the significant majority of the Medicaid billing documents provided by Flamingo Eye,” Senta wrote in the charges.

Examples included:

— Employees filing timesheets indicating they provided three hours of daytime rehabilitation services to six people individually in a single shift.

— Timesheets that reported clients were taken to businesses on holidays at times that the businesses were closed.

— Timesheets that were identical to the same day in every other month that calendar year.

— Timesheets that showed employees overseeing two different residences on the same shift, though the model calls for an employee to oversee a single residence on a shift.

An investigator with the state’s Medicaid Fraud Control Unit spoke with several lower-level employees after discovering the paperwork discrepancies, Senta wrote in the charges.

Each of the employees admitted they had filled out documents that weren’t true, or were true but later changed by supervisors, or were true and were disregarded by supervisors while billing Medicaid, Senta wrote.

In one instance, an employee recorded that he had taken two clients to baseball fields for exercise, which should have been billed at a group rate. From there, upper managers took his report and intentionally billed Medicaid as if the services were one-on-one, a much-higher rate, the charges say.

Another employee said he took a client to the Fifth Avenue Mall for daytime rehabilitation between 8:30 and 9:15 in the morning. That wasn’t possible, since the mall was closed at that time, Senta wrote.

In such cases, Williams was paid personally at an inflated rate for the services, the charges say. Overall, she had been paid an average of $1.45 million from Medicaid every year since 2012, according to the charges.

Other complaints from lower-level staff involved the company either not providing services or providing services that were unsafe. The Medicaid fraud investigator reported an instance of an upper manager doctoring a report of a medical emergency to make it appear that 911 had been called right away, when that was not the case, Senta wrote in the charges.

The company faces a maximum fine of $2.5 million. Williams, the owner, faces up to 10 years in prison, a fine of $100,000 and restitution to the state Medicaid program.

Sentencing has been set for January. An attorney for both Williams and the company, Chester Gilmore, didn’t immediately return a call seeking comment.

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Challenger Betting That Medicaid Problems Will Convince Iowans To Change To New Governor

WEST DES MOINES, Iowa–Fred Hubbell, a retired Des Moines business man and philanthropist, is making the Branstad-Reynolds administration’s 2016 decision to privatize Medicaid delivery services the main thrust of his Democratic campaign for governor this week.

Hubbell met Tuesday with about a dozen organizations that provide care to Iowans with physical, mental or developmental challenges. “Beginning day one, we’re going to change this system,” Hubbell pledged to the group if elected governor.

Nearly 700,000 disabled and low-income Iowans receive Medicaid services.

Hubbell’s running mate, State Senator Rita Hart of Wheatland, headlined Medicaid round table campaign events scheduled Wednesday in Ames, Mason City and Cedar Rapids.

Providers, recipients and family members have complained ever since former Governor Terry Branstad, a Republican, shifted management of the Medicaid delivery system to private companies. Critics say the companies put profit over patient care and have reduced services and reimbursements, which endangered the health of recipients and threatened the financial ability to providers to stay in business. The providers expressed those concerns Tuesday afternoon to Hubbell at Link Associates in West Des Moines, an organization of 300 employees that offers services to 900 people with intellectual disabilities.

Hubbell said that he would shift much of the system back under state management, although he said it would take months for the full transition to occur. Branstad and his successor, Governor Kim Reynolds, have claimed privatization would save taxpayers hundreds of millions. Although, Reynolds’ administration has faced criticism for failing to document the specific savings the switch has realized. 

Hubbell wouldn’t say how much his plan would cost the state. “That’s a great question,” when Channel 13 asked him for a figure, “We don’t even know what we’re spending today.”

Reynolds’ administration agreed to increase payments to the private companies managing Medicaid by 7.5 percent in the coming year, which will mean more than $100 million in additional costs to the state treasury.

Reynolds claims that the system is getting better. She acknowledged after becoming governor in May, that her predecessor may have rushed the privatization. But she has appointed Mike Randol as the new Medicaid director in the state.

Her campaign released a statement following Hubbell’s criticism of the system:

“Governor Reynolds is focused on getting results and help for every Iowan who relies on this Medicaid system. She is fighting to create affordable health care options for farmers, small business owners, and hard working Iowans. Earlier this year she signed comprehensive, bipartisan mental health care reform into law. Her opponent wants to go back to a broken, unsustainable system that could not guarantee long-term health care for vulnerable Iowans.”

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Gov. LePage urges feds to reject Medicaid expansion for Maine

Gov. Paul LePage is urging the Trump administration to reject Maine’s request to expand Medicaid coverage.

Voters last year approved expanding Medicaid coverage to between 70,000 and 90,000 low-income Mainers.

The Maine Supreme Court last month ordered the LePage administration to submit what is called a state plan amendment to the federal government. The plan was submitted this week.

The plan notifies the federal government of the state’s plans to expand Medicaid coverage under the Affordable Care Act.

In a letter accompanying the state plan amendment, LePage urged the federal government to deny Maine’s request due to a lack of dedicated state funding.

“CMS should not accept an SPA (state plan amendment) in circumstances in which the state has no legislative commitment ensuring that it can comply with its obligations,” the letter said.

Joan Clinton, who is technically eligible for Medicaid coverage under the expansion approved by voters, has had her application denied as the legal battle continues.

“The energy that’s been put into fighting on both sides, if that could be put into ‘How do we make this work?’ Well, that would be much better,” Clinton said.

An attorney for supporters of Medicaid expansion said the governor’s latest attempts to block it are troubling but not surprising.

“The statute says — and the court’s order said — that they should file a plan that ensured eligibility, and this is a plan that is submitted with the express intention of preventing eligibility,” attorney Jamie Kilbreth said.

Kilbreth said the law is the law.

“There’s nothing about the CMS review process that anything the governor said should affect,” Kilbreth said.

The federal government has 90 days to act on the plan filed by the state. Kilbreth said he plans to file a rebuttal to the governor’s letter.

The next court date in the legal battle over Medicaid expansion is Sept. 27.


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Warren Dentist John Durmon Charged with Medicaid Fraud

by Arkansas Business Staff 
on Wednesday, Sep. 5, 2018 4:53 pm  
1 min read

A south Arkansas dentist has been arrested and charged with two counts of Medicaid fraud totaling more than $185,000.

Dr. John Durmon of Warren turned himself in to the Pulaski County Sheriff’s Department after an investigation by the state Attorney General Leslie Rutledge’s office, which announced the arrest.

Durmon allegedly submitted 2,557 claims for X-rays for 85 Medicaid recipients from October 2016 through December 2017. Durmon was paid $153,078 for the claims, although the AG’s office said Durmon had not properly taken, developed, used or maintained X-rays as required by Medicaid regulations.

Durmon is also accused of submitting 637 false claims for various dental services for 33 Medicaid recipients from September 2015 through December 2017. Durmon was paid $33,383 for the claims, although the investigation concluded that the services were never provided.

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Hubbell hears of chaos in Medicaid for intellectually disabled Iowans

Candidate Fred Hubbell and Shelley Chandler of Iowa Association of Community Providers.

Fred Hubbell, the Democratic candidate for governor, met this afternoon with leaders of agencies that provide care for about 15,000 intellectually disabled Iowans.

“This is a big group in our state that is not being treated very well,” Hubbell said.

The group warned that the state’s privatized Medicaid system is creating chaos for their intellectually disabled clients. Some who cannot live on their own are being denied in-home care or being sent to nursing homes. Kelsey Clark of Madrid, an advocate for Medicaid patients, said having out-of-state companies manage care for intellectually disabled Iowans is leading to “human tragedy” and may force some providers to close.

“If something is not done, there will be issues that you can’t come back from,” Clark said.

Clark and other advocates told Hubbell denying care or just not paying bills are the only ways the managed care companies can “make money” on Medicaid clients who are intellectually disabled, since their care isn’t about health or wellness, but about daily living. Hubbell has pledged to start making changes in the Medicaid system on day one if he’s elected governor.

“This population needs to have a focus on quality of care, keeping them out of institutions and giving them the support and services that they need,” Hubbell told reporters after Tuesday’s meeting.

Shelley Chandler of the Iowa Association of Community Providers said Iowa is the only state that has private companies managing “non-medical care” for its intellectually disabled residents.

“Hospitals and nursing homes and doctors get maybe 25-30 percent of their revenue from Medicaid,” Chandler said. “The providers around the table and the 135 providers we represent around Iowa — 100 percent of their income comes from Medicaid.”

Former Governor Terry Branstad ended the state-managed, fee-for-service Medicaid system on April 1, 2016. The state is paying two private companies to manage care for about 680,000 Iowans on Medicaid today.

Governor Kim Reynolds has acknowledged there were hiccups in the transition to managed care, but she has said the privatized system is helping to control costs for the state. A Reynolds campaign spokesman said late this afternoon that the governor “is focused on getting results and help for every Iowan who relies on this Medicaid system.”

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State files Medicaid expansion plan with federal government, advocates say

Advocates for Medicaid expansion in Maine said Tuesday that the state has filed an expansion plan with the federal government.

The move comes after last month’s decision by the Maine Supreme Court to dismiss an appeal by the LePage administration of court orders requiring Maine to file paperwork to seek federal funding for expansion.


The justices said those orders are in effect.

Medicaid expansion supporters told WMTW News 8 political reporter Paul Merrill that the Maine Department of Human Services filed the expansion plan Tuesday.

Mainers voted last November voted to allow adults under age 65 with incomes at or below 138 percent of the federal poverty line to apply for Medicaid coverage starting July 2.


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Governor submits Medicaid plan, urges feds to reject it

Maine’s Republican governor has urged the federal government to reject the proposal that his administration submitted Tuesday to start rolling out Medicaid expansion as demanded by voters.

Gov. Paul LePage in an Aug. 31 letter asked President Donald Trump’s administration to quash the proposal because Maine doesn’t know how it’ll cover its share of expansion down the road. Previously, LePage has said he’d rather go to jail than jeopardize Maine’s finances by expanding Medicaid.

The governor in his letter said he accepts that Medicaid expansion is the law. “However, not one dime of the hundreds of millions of dollars that will be needed to pay for the state’s share of expansion has been appropriated,” LePage wrote.

Nearly 3 out of 5 Mainers last November voted to allow adults under age 65 with incomes at or below 138 percent of the federal poverty line to apply for Medicaid coverage starting July 2.

Medicaid expansion could eventually send roughly $500 million in annual federal funding to Maine. But the voter-approved law doesn’t include a way for Maine to pay $54 million to $62 million for its annual share of expansion after projected savings.

The governor denies that Medicaid expansion will save Maine between $25 million and $27 million each year. This summer he vetoed a bill to hire over 100 new Medicaid staffers and make sure Maine has enough money for its first year of expansion.

Pro-expansion groups sued the LePage administration for failing to file paperwork to receive federal expansion funding by an April deadline. A legal battle ensued, and state courts have since ordered Maine to file that Medicaid expansion plan.

But Maine courts have yet to settle whether lawmakers have to actually earmark money for Maine’s share of expansion, or whether the state can rely on left-over Medicaid funds in state coffers. A spokesman for the U.S. Centers for Medicare & Medicaid Services told The Associated Press in April that the federal review of Maine’s Medicaid expansion plan could include asking about a state’s funding mechanism.

The LePage referenced the governor’s letter when it submitted its plan Tuesday. A state Department of Health and Human Services spokeswoman said that Maine has complied with the court order.

“I cannot overemphasize the risk that the approval of this (state plan amendment) will place on existing populations based on the fact that our existing budget will be utilized to cover all populations — old and new,” Acting DHHS commissioner Bethany Hamm said in the Tuesday letter to federal regulators.

The fact that Hamm’s letter cited the governor’s letter calls into question whether the plan is complying with the court order in “good faith,” said an attorney for Maine Equal Justice Partners. The LePage administration’s plan proposes to launch Medicaid expansion on Sept. 4, instead of retroactively from July 2.

“For the state instead to do everything it can imagine to delay or defeat approval of expansion represents defiance of the undeniable constitutional power of the voters to enact this law…” Dingman said.

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