Blog Archives

Is Health Care Fraud on the Rise? Or Just the Accusations??

Recent stories in the news seem to suggest that health care fraud is running rampant.  We’ve got stories about Eric Leak‘s Medicaid agency, Nature’s Reflections, funneling money to pay athletes, a seizure of property in Greensboro for alleged Medicaid fraud, and, in Charlotte, a man was charged with Medicaid fraud and sentenced to three years under court supervision and ordered to pay $3,153,074. And these examples are local.

Health care fraud with even larger amounts of money at stake has been prosecuted in other states.  A nonprofit up in NY is accused of defrauding the Medicaid system for over $27 million.  Overall, the federal government opened 924 criminal health care fraud investigations last year.

What is going on? Are more people getting into the health care fraud business? Has the government become better at detecting possible health care fraud?

I believe that the answer is that the federal and state governments have determined that it “pays” high dividends to invest in health care fraud investigations.  More and more money is being allocated to the fraud investigative divisions.  More money, in turn, yields more health care fraud allegations…which yields more convictions….and more money to the government.

Believe me, I understand the importance of detecting fraud.  It sickens me that those who actually defraud our Medicaid and Medicare systems are taking medically necessary services away from those who need the services.  However, sometimes the net is cast so wide…so far…that innocent providers get caught in the net.  And being accused of health care fraud when you innocent is a gruesome, harrowing experience that (1) you hope never happens; and (2) you have to be prepared in case it does.  I have seen it happen.

As previously stated, in fiscal year (FY) 2014, the federal government opened 924 new criminal health care fraud  investigations.  That’s 77 new fraud investigations a month!!  This number does not include civil investigations.

In FY 2012, the Department of Justice (DOJ) opened 2,016 new health care fraud investigations (1,131 criminal, 885 civil).

The Justice Department launched 903 new health-care fraud prosecutions in the first eight months of FY 2011, more than all of FY 2010.

These numbers show:

  • an 85% increase over FY 2010,
  • a 157% increase over FY 2006
  • and 822% over FY 1991.

And the 924  investigations opened in fiscal 2014 only represent federal investigations.  Concurrently, all 50 states are conducting similar investigations.

What is being recovered? Are the increased efforts to detect health care fraud worth the effort and expenditures?

Heck, yes, it is worth it to both the state and federal governments!

Government teams recovered $4.3 billion in FY 2013 and $19.2 billion over the last five years.  While still astronomically high, the numbers dropped slightly for FY 2014.  In FY 2014, according to the Annual Report of the Departments of Health and Human Services and Justice, the federal government won or negotiated over $2.3 billion in health care fraud judgments and settlements.  Due to these efforts, as well as efforts from preceding years, the federal government retrieved $3.3 billion from health care fraud investigations.

So the federal and state governments are putting more money into investigating health care fraud.  Why?

The Affordable Care Act.

Obviously, the federal and state governments conducted health care fraud investigations prior to the ACA.  But the implementation of the ACA set new mandates to increase fraud investigations. (Mandates, which were suggestions prior to the ACA).

In 2009, Barack Obama signed Executive Order 13520, which was targeted to reduce improper payments and to eliminate waste in federal programs.

On March 23, 2010, President Obama signed the ACA into law.  A major part of the ACA is focused on cost containment methods. Theoretically, the ACA is supposed to be self-funding.  Detecting fraud, waste and abuse in the Medicare/Medicaid system helps to fund the ACA.

Unlike many of the other ACA provisions, most of the fraud and abuse provisions went into effect in 2010 or 2011. The ACA increases funding to the Healthcare Fraud and Abuse Control Program by $350 million over the next decade. These funds can be used for fraud and abuse control and for the Medicare Integrity Program.

The ACA mandates states to conduct post payment and prepayment reviews, screen and audit providers, terminate certain providers, and create provider categories of risk.

While recent articles and media seem to indicate that health care fraud is running rampant, the substantial increase in accusations of health care fraud really may be caused by factors other than more fraud is occurring.

The ACA mandates have an impact.

And, quite frankly, the investigation units may be a bit overzealous to recover funds.

What will happen if you are a target of a criminal health care fraud investigation?

It depends whether the federal or state government is conducting the investigation.

If the federal government is investigating you, most likely, you will be unaware of the investigation.  Then, one day, agents of the federal government will come to your office and seize all property deemed related to the alleged fraud.  Your accounts will be frozen.  Whether you are guilty or not will not matter.  What will matter is you will need an experienced, knowledgeable health fraud attorney and the funds with which to compensate said attorney with frozen accounts.

If the state government is conducting the investigation, it is a little less hostile and CSI-ish.  Your reimbursements will be suspended with or without your notice (obviously, you would notice the suspension once the suspension occurred).  But the whole “raid on your office thing” is less likely.

There are legal remedies available, and the “defense” should begin immediately.

Most importantly, if you are a health care provider and you are not committing fraud, you are not safe from accusations of fraud.

Your insurance, most likely, will not cover attorneys’ fees for alleged intention fraud.

The attorney of your choice will not be able to accept funds that are “tainted” by alleged fraud, even if no fraud occurred.

Be aware that if, for whatever reason, you are accused, you will need to be prepared…for what you hope never happens.

Broken Promises and the NC Waiver: You Do NOT Get Your Choice of Provider!!

“One can talk good and shower down roses, but it’s the receiver that
has to walk through the thorns, and all its false expectations.” –Anthony Liccione

In the 1968 Presidential campaign, Richard Nixon stated that “new leadership will end the war” in Vietnam. Also, in a 1968 interview, Nixon said he had “no magic formula” or “gimmick” for ending the Vietnam War. Then, in his memoirs, Nixon stated he never claimed to have such a plan. This is called a broken election promise.

Sadly, Richard Nixon’s broken election promise was not the first, nor would it be the last. We have become used to politicians making election promises and breaking those same promises which got them elected once they are in office.

“If you like your doctor, you can keep your doctor. If you like your health care plan, you can keep your health care plan.”

“Read my lips: no new taxes.”

Over the last few years, I have written ad nausem about accountability and proper supervision when it comes to the Managed Care Organizations (MCOs) in North Carolina. The other day, I was reviewing some pertinent federal regulations and came across this:

§ 438.52 Choice of MCOs, PIHPs, PAHPs, and PCCMs.

• General rule. Except as specified in paragraphs (b) and (c) of this section, a State that requires Medicaid beneficiaries to enroll in an MCO, PIHP, PAHP, or PCCM must give those beneficiaries a choice of at least two entities.

Obviously, North Carolina is not adhering to the above-referenced requirement.

Pull up the Waiver. In order to offer Medicaid enrollees only one MCO or other such entity, North Carolina would have had to request a waiver of 42 CFR § 438.52.If you rely on Medicaid for behavioral health care and live in Wake County, you have no choice but to rely on the provider network of only entity, Alliance Behavioral Health (Alliance), to receive services. For example, you do not get to choose between Alliance’s provider network and Eastpointe Behavioral Healthcare’s (Eastpointe) provider network. Staying with the same theoretical hypothesis, if your provider was not anointed with the gift of being in Alliance’s network, then you do not get to stay with your provider.

“If you like your doctor, you can keep your doctor. If you like your health care plan, you can keep your health care plan.”

Similar to President Barack Obama’s contention quoted above, we made similar promises to the Center for Medicare and Medicaid Services (CMS). Our promises are found within our Waivers. We have two Waivers, one for the developmentally disabled population and one for the mentally ill/substance abuse population. Each Waiver waives certain federal exceptions. However, in lieu of the federal requirements, we make certain promises to CMS. In order to waive 42 CFR § 438.52, we made certain promises to CMS in order to circumvent the necessary provisions of 42 CFR § 438.52.

The State sought a waiver of section 1902(a)(4) of the Act:

“The State seeks a waiver of section 1902(a)(4) of the Act, which requires States to offer a choice of more than one PIHP or PAHP per 42 CFR 438.52. Please describe how the State will ensure this lack of choice of PIHP or PAHP is not detrimental to beneficiaries’ ability to access services.”

Here are our promises:

“Under these circumstances, the State does not believe that making only one plan available in each geographic area of the State will negatively impact recipients’ access to care.”

“The LMEs have decades of experience locating and developing services for consumers with MH/IDD/SAS needs, and over the years, have built strong and collaborative working relationships with the providers of these services.”

“These providers support this initiative and consumers have at least as much choice in individual providers as they had in the non-managed care environment.

“Enrollees will have free choice of providers within the PIHP serving their respective geographic area and may change providers as often as desired. If an individual joins the PIHP and is already established with a provider who is not a member of the network, the PIHP will make every effort to arrange for the consumer to continue with the same provider if the consumer so desires.

“If you like your doctor, you can keep your doctor. If you like your health care plan, you can keep your health care plan.”

My two personal favorites among the State’s promises to CMS are: (1) “consumers have at least as much choice in individual providers as they had in the non-managed care environment;” and (2) the PIHP will make every effort to arrange for the consumer to continue with the same provider if the consumer so desires.”

These promises, in reality, are utter horsefeathers.

Over and over my provider clients come to me because one of the MCOs has terminated their Medicaid contract, usually for absolutely no valid reason. Over and over my provider clients tell me that their consumers are devastated by the news that they may lose their provider. I have had consumers contact me to beg me to help the provider. I have had consumers appear in court stating how much they want that particular provider. I have had provider clients cry in my office because their consumers are so upset and regressing because of the news that they may have to find another provider.

Yet, we have promised CMS that consumers have just as much choice in providers than when there was no managed care.

In the words of Dorothy from the Wizard of OZ, “You ought to be ashamed of yourself. Frightening him like that when he came to you for help.”

Similarly, our Medicaid recipients go to their providers for help. They create relationships…trust…bonds. And the MCOs are terminating these very providers, most for invalid and erroneous reasons, and, certainly, without the consideration of our promise to CMS.

But, remember, we are told the PIHPs will make every effort to keep the consumer with the chosen provider…

It would be interesting to do a public records request as to how many providers have been terminated by the MCOs in the last 2 years. Because, even if only 1 provider were terminated in the past 2 years and its consumers still wanted to go to that particular provider, then our State has broken its promise.

Apparently, due to my outspoken positions, DHHS will no longer honor my public records requests, which I think is absolutely preposterous. I am, still, a paying taxpayer last time I checked, which is every pay-day when I only get 60% of my wages. If any of you would submit this public records request, please forward it to me. I would be grateful for the information.

Mass Medicare and Medicaid Payment Suspensions Increase Based on “Credible Allegations of Fraud”

One way in which President Obama pushed the Affordable Care Act (ACA) through Congress was the promise that the ACA would, basically, fund itself by the increase in recoupments from providers for fraud, waste, and abuse…hence, the dramatic increase in audits and payments suspensions for both Medicare and Medicaid providers.

Herein lies the problem, by relying on you, who accept Medicare and Medicaid to fund, even a portion, of the ACA, we are de-incentivizing you, as a health care providers, to accept Medicare and Medicaid. Think about this logically, we are placing MORE people in a system (by expanding Medicaid), more people will rely on Medicare and Medicaid as their health insurance, but we are incentivizing FEWER providers to accept Medicaid and Medicare. It is as though we don’t care what happens to the people once we give them insurance. The goal of the ACA seems to be: get more people insured; instead of having the goal to allow everyone to get health care.

But I digress…

Section 6402(h) of the ACA requires suspension of Medicare and/or Medicaid payments when there is a credible allegation of fraud. Before the ACA, the suspension was not mandatory.

So, what constitutes a credible allegation of fraud?

Let me give you a real life example. One of my clients, we will call it Company Good Health, had its Medicare and Medicaid payments suspended based on an anonymous letter claiming Good Health commits Medicaid fraud and sent to the Division of Health and Human Services (DHHS) with no name of the author or return address. Therefore, DHHS had no way to contact the anonymous author to verify whether any sentence within the letter had an ounce of veracity. In fact, the author of the letter may very well have been an ex-girlfriend of the CEO or a bitter competitor for business. There is no way to know.

Yet, according to the ACA, an allegation of fraud is credible if it has an “indicia of reliability.” Look up “indicia.” I did. I found “from Latin plural of indicium (“a notice, information, discovery, sign, mark, token”).” I thought, that’s an unhelpful definition, so I looked up indicia in my legal dictionary, Black’s Law Dictionary. I found, in part, “[t]he term is much used in Civil Law in a sense nearly or entirely synonymous with Circumstantial Evidence. It denotes facts that give rise to inferences, rather than the inferences themselves.” Facts that give rise to inferences. Circumstantial evidence is evidence which may allow a judge or jury to deduce a certain fact from other facts which can be proven. In some cases, there can be some evidence that cannot be proven directly, such as with an eye-witness. (Think of the Scott Peterson trial).

Under the ACA, if there is a fact that gives rise to an inference of an allegation of fraud, the your Medicare and Medicaid reimbursements must be suspended. I underlined the words in the preceding sentence “inference,” “allegation,” and “must” to emphasize the slight and without any factual verification circumstance may be that causes suspension of payments. For many of you, this suspension is financially debilitating and will cause you to go out of business…or, at the very least, never accept Medicare or Medicaid again. Suspensions of payments do not only affect you, if affects your recipients as well.

An example of a mass suspension can be found in our nation’s capital. Recently, in D.C., the Medicaid agency suspended payments to 52% of the city’s home health agencies for personal care services (PCS). The companies hired an attorney and got a temporary restraining order (TRO) preventing the city from withholding funds, but lost at the preliminary injunction.

In an Order denying the preliminary injunction, the Judge stated that “in contrast to a provider’s right to participate in the Medicaid program, there is no constitutional right to receive Medicaid payments.” (To which I disagree, because there is a right to Medicaid payments for services rendered. National case law from multiple jurisdictions illustrates this, but maybe it was not argued before or accepted by this judge).

The Center for Medicare and Medicaid (CMS) has also suspended Medicare payments on a large-scale. CMS suspended Medicare payments to 78 Dallas area home health providers. Last year’s “Health Care Fraud and Abuse Control report” stated that 297 providers were under “active suspension” from Medicare and 105 more suspensions were approved.

Another example of a mass suspension is the behavioral health providers in New Mexico. In June 2013, the Health Services Division (HSD) suspended all reimbursements for 15 behavioral health care providers, all of whom accounted for 87% of New Mexico’s behavioral health care, based on credible allegations of fraud. Most accused providers went out of business.

While both Medicare and Medicaid require the suspension of reimbursements upon a credible allegation of fraud, you are slightly more protected. Medicare suspensions end after 18 months and can only be extended from 6 months in special circumstances.

There is no such protection for you when it comes to Medicaid; the states make the rules. There is a good cause exception that allows the state NOT to suspend payments, but, to date, I have yet to witness one good cause exception being recognized by the state. Instead, relief for the accused providers only comes from filing a lawsuit, most likely, an injunctive lawsuit. The downside of filing a lawsuit is that you have to pay attorney’s fees, which can be daunting, and you must find an attorney that specializes in Medicare and Medicaid. I have seen too many inexperienced, but well-intended, attorneys create bad law for providers due to self-imposed, legal stumbles.

The enigma within the language of the ACA, in this particular section, is the complete disregard for due process. See my blog on “How the ACA Has Redefined the Threshold for “Credible Allegations of Fraud” and Does It Violate Due Process?”  By suspending Medicare and Medicaid reimbursements due to “indicia of reliability of an allegation of fraud,” the government is usurping your right to payment for services rendered without notice and an opportunity to be heard, which is one of the bedrocks of our Constitution.

So what are you to do if you are caught up in this web of mass suspensions based on “indicia of reliability of an allegation of fraud?”

Contact your Medicare and Medicaid litigation attorney!  And do NOT forget to fill out the “good cause” exception…just in case…

Knock, Knock. Who’s There? Burwell. Burwell Who?

As I am sure most of you have heard, April 10, 2014, Kathleen Sebelius, former Secretary to Health and Human Services (HHS), resigned. Some journalists wrote that her resignation came 6 months after “the disastrous rollout of Obamacare,” obviously alluding that she was fleeing from her position as Secretary. But is that why Sebelius left? And who is Sylvia Mathews Burwell?

It is no secret that when went live on October 1, 2013, Sebelius called the roll-out a “debacle.” But recent figures show enrollment in Obamacare exchanges has surpassed 7.5 million.

Sunday Sebelius stated that “Clearly, the estimate that it was ready to go Oct. 1 was just flat-out wrong.”

According to Politico Pro, “a White House official said Sebelius told Obama in March that she planned to resign. She felt that the Affordable Care Act trajectory was back on track, and believed “that once open enrollment ended it would be the right time to transition the Department to new leadership.””

It seems that Sebelius did not want to resign during the height of the debacle. She waited until things smoothed out a bit before walking away.

Obama has chosen Sylvia Mathews Burwell, his budget Director, to replace Sebelius.

Who is Burwell?


Burwell served as deputy White House chief of staff during the Clinton administration. She also served at the Office of Management and Budget (OMB) twice, once as director. She has also worked at the Bill and Melinda Gates Foundation. (Speaking of Bill and Melinda Gates Foundation and people with obscene amounts of money, why don’t people ever set up charities to pay for Medicaid recipients to receive private insurance with the co-pays all covered? If I ever get an obscene amount of money I would set up a Medicaid Foundation. The Emanuel Medicaid Foundation. Look for that in the VERY FAR future, folks.).

Going back to Burwell…she received her bachelor’s degree in government from Harvard University. She also received her bachelor’s degree in philosophy, politics and economics from Oxford University. Seriously? Is that a quadruple major from 2 colleges?

Her grandparents were Greek immigrants, and she grew up in West Virginia.

There isn’t much more information on Burwell. She is relatively young (48) and holds a relatively small resume considering the enormous undertaking she is about to assume.

Obama nominated Burwell one day after Sebelius resigned. There is no indication of whether Burwell was Obama’s first choice. It took him one day to replace Sebelius, which is pretty amazing.  Remember, we still haven’t replaced former Medicaid Director, Carol Steckel. Sandy Terrell is still the “Acting Director.” Whew, it has got to be difficult to fill these intimidating positions.

I can only imagine how many people would NOT want to be Secretary of HHS. Talk about a big job! Talk about high stress!

Burwell has not been confirmed yet. Despite Burwell not being a common household name when Obama nominated her, it is without question that Burwell has now stepped into the limelight. If confirmed, Burwell will be one of the most powerful people in health care…and one of the most scrutinized.

Good luck, Burwell!! Make Burwell a household name…for good reasons. And when someone says, “Burwell who?”

Someone else will respond, “That is the Secretary for HHS.”

Obama Voices the Need for Access to Mental Health Care: Medicaid Recipients, Too?

Two days ago, Obama voiced that gun control and mental health care reform is on the horizon.  Since the terrible massacre at Sandy Hook Elementary School, people, especially politicians, have been talking about gun control.  The thinking behind this is that if the shooter at Sandy Hook did not have access to guns, the murders would not have happened.  Agreed.

But think of this:  If a child puts his or her finger in a light socket and gets electrocuted, do we cut off the power to the entire house forever? Or do we educate that child so he or she does not do it again?

Personally, I opt for the latter:  Educate.

If the child is incapable of understanding the concept of getting electrocuted by placing his or her finger in a light socket (i.e., the child has mental health issues), then, as a parent, I would seek mental health services for my child.  I still would not opt to cut off the power in the house.

Mental health services are vital.  Mental health services are important for all people. But since this is a Medicaid blog, I will focus on mental health services for Medicaid recipients.  Medicaid recipients need access to quality mental health services. Quite possibly, in the world of Medicaid, mental health services may be the most needed and least provided to recipients (maybe dental and specialities in medicine are also in the top most needed and least provided, but I will cover those topics in another blog).

I’m not talking about mental health services for the autistic children or children suffering from an easily diagnosed and highly recognizable mental health illness. These children obviously need mental health services.  In my opinion, most people would agree as to the need for mental health services to these children.  No, I’m talking about the thirteen year old girl who has so much anger built up inside that she begins to cut herself, torture animals and scream at her teachers. Or the 14-year-old boy, who was sexually abused by his uncle and is now exploring the sexuality of the 6 and 7-year-old boys in the school  bathroom. The 12-year-old boy who has no friends, is isolated at school, and is publicly ridiculed until he begins to think he has no reason to live and begins fantasizing about killings, both of himself and others…the ones who ridicule him.

Would wonderful access to mental health services for Medicaid recipients have stopped Sandy Hook from happening? Probably not. But future tragedies can be stopped by providing quality mental health services to all, especially to Medicaid recipients.  According to Obama’s recent speech, Obama agrees that quality mental health care needs to be accessible to all people.  But does that also mean Medicaid recipients? Medicaid recipients must meet criteria to receive therapy (after a certain number of visits).

Medicaid recipients rely on the Medicaid system for mental health services. I don’t mean to state the obvious, but think about it. People with private health insurance have choices about therapists. I can say, “I’m feel like my depression is overwhelming.” And schedule a psych visit for the next week. Not Medicaid recipients. Medicaid recipients need (for the most part) prior authorization. Which means if a Medicaid recipient feels low…really low…as in, needs a psychiatrist low, they need permission from the State.   A State-contracted agent must review the documents and determine it is medically necessary for that Medicaid recipient to receive therapy.  Although, for Outpatient Behavioral Services,

This is the criteria for a Medicaid recipient to receive Outpatient Behavioral Services:

Entrance Criteria

ALL of the following criteria are necessary for admission of a beneficiary for outpatient treatment services:

a.   A Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,Text Revision (DSM-IV-TR) (or its successors) Axis I or II diagnosis.

b. Presentation with behavioral, psychological, or biological dysfunction and functional impairment, which are consistent and associated with the DSM-IV-TR (or its successors) Axis I or II diagnosis.

c. Does not require a higher level of care.

d. Capable of developing skills to manage symptoms, make behavioral changes,and respond favorably to therapeutic interventions.

e. There is no evidence to support that alternative interventions would be more effective, based on North Carolina community practice standards (e.g., Best Practice Guidelines of the American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, American Board of Addiction Medicine).

Medicaid beneficiaries under 21 and NCHC beneficiaries are allowed 16 unmanaged visits; adults are allowed eight unmanaged visits per calendar year. All visits beyond these limitations require prior approval.

More than eliminating guns (or cutting the power off in the house), Medicaid recipients need somewhere to go to receive quality health care with no judgment and not all this criteria. If a Medicaid recipients wants to attend weekly therapy sessions, shouldn’t the Medicaid recipient be able to go to therapy without needing an Axis I or II diagnosis? Why does a Medicaid recipient need to be diagnosed with an Axis I or II diagnose in order to receive outpatient therapy?

So now Obama has publicly announced that, along with gun control measures, he plans to tackle the issue of mental health care.  I ask, “How?” and “Does this include access to therapy for Medicaid recipients?” The fact is that Medicaid recipients can see a therapist 16 (if a child) and 8 (if an adult) times. But then, the Medicaid recipient must show medical necessity in order to receive therapy. Is this quality mental health care? Is this access to quality mental health care for ALL?


The NC Medicaid System is Broken: FIX IT!!

People covered by Medicaid receive worse medical service than people with private insurance.  This is a fact.  It is a sad fact, but a fact nonetheless.  Hundreds of studies have shown this fact.  Here are a few:

A recent study published in the New England Journal of Medicine examined pediatric access to specialty clinics in Cook County, Illinois.  The study sent out research assistants posing as mothers and making phone calls to a random sample of specialty clinics, the study found a significant disparity between access to specialty care for privately insured children and children on Medicaid as well as the publicly funded Children’s Health Insurance Program (CHIP). Specifically, the researchers noted more denials of appointments as well as longer waiting times for Medicaid and CHIP patients than for privately insured patients.

A very scary study conducted on North Carolina‘s Medicaid in 2010 published in the State Center for Health Statistics, found that the North Carolina Medicaid population experiences a much higher rate of overdose deaths than the North Carolina population. This study suggests that fatal overdose among the Medicaid population are associated with claims for mental health disorders, substance abuse, and routine medical care for pain management.

A 2000 study published in the American Journal of Public Health that examines colorectal cancer treatments and outcomes found that Medicaid patients not only had higher mortality rates, but were also less likely to receive cancer-directed surgery, than patients using commercial fee-for-service insurance.

A 2010 study in the Journal of Hospital Medicine found similar results for non-cancer-related illness. In this study, the authors examine the relationship between insurance status and health outcomes for myocardial infarction, stroke, and pneumonia patients.  The authors statistically analyzed a nationally representative hospital database and noticed, even after adjusting for factors such as age, gender, income, other illnesses, and severity, higher in-hospital mortality rates for Medicaid patients than for privately insured patients. Additionally, even after adjusting for these factors, the study found that Medicaid patients hospitalized for strokes and pneumonia also ran up higher costs than the privately insured, as well as the uninsured.

A 2012 study in Health Affairs examined physicians’ willingness to accept new patients. Using survey data from a nationally representative sample, the study found that nearly one-third of physicians nationwide will not accept new Medicaid patients. Doctors in smaller practices, as well as doctors in metropolitan areas, are among the least inclined to accept new Medicaid patients.

So, with the understanding that  the Medicaid system  is failing those very people it is designed to protect, why are our political leaders ignoring the broken system and merely dumping more people into the failing Medicaid system????

With Obamacare‘s Medicaid expansion, hundreds of thousands of people will be dumped into this broken Medicaid system with zero political effort to FIX the system. In NC alone, if we expand our Medicaid, approximately 720,000 more North Carolinians will be Medicaid eligible.

Obama proponents would, most likely, argue that Obama raised the Medicaid reimbursement amount to physicians to meet the Medicare reimbursement rate. Raising the Medicaid reimbursement rate tempts more physicians to accept Medicaid.

I agree with the last sentence of the above paragraph. Raising the Medicaid reimbursement rate WOULD cause more physicians to accept Medicaid. But that is not what Obamacare does.  Obamacare does not raise the Medicaid rate to all physicians, only primary care physicians, and only temporarily.  And even the raised rate for primary physicians is nominal, at best. Because, during the 2012 election,  while Obama was standing on his platform of higher Medicaid reimbursement to physicians…up to the Medicare rate….Obama was slashing the Medicare reimbursements. It’s the old bait and switch. GOTCHA!

Again I ask: Why are our political leaders ignoring the broken system and merely dumping more people into the failing Medicaid system????

Medicaid expansion will cause more people to be declined medical treatment by providers, cause people to receive sub-par health services, and to the extreme, cause deaths when those deaths should not have happened.

Unintentional overdosed (UO) deaths have become the second leading cause of unintentional injury deaths in the United States, exceeded only by motor vehicle injuries. (1)  North Carolina UO death rates exceed the national average.  The Medicaid population represented approximately 20 percent of the overall state population in 2007, but it experienced one-third of the unintentional overdose deaths.  (2)

Instead of expanding Medicaid to more people,  our leaders need to fix the Medicaid system first. Fixing the Medicaid system should be the number one top priority.  Not exasperating the problem by dumping 720,000 more North Carolinians into the Medicaid system. FIX IT!! 

Make sure that if I hold a Medicaid card that (1) I am able to get an appointment with the proper physician; (2) that the physician I visit does the very best he or she can to ameliorate my problem (as if I were on private insurance); (3) provide me with any needed test to determine the cause of my problem; (4) allow me to have follow up appointments.

In essence, those with Medicaid should receive the same care as those on Blue Cross (not saying Blue Cross in the bee’s knees).



Obamacare Medicaid: All or Nothing!!

On Monday, the Feds said, “NO!” to partial participation for states in the federal Medicaid plan. Now the states will need to decide to expand Medicaid per Obamacare (“go all in”) or not (“fold”).

For the past few months, we have heard governor-elect Pat McCrory state that he was interested, as were most Republican governors, in a partial participation in the  federal expansion of Medicaid.  Meaning, the states would expand Medicaid, but not quite as much as Obamacare requires. Well, this is no longer an option.

Monday, Secretary of Health and Human Services Kathleen Sebelius, authored a memo that stated “the law does not provide for a phased-in or partial expansion.”  Sebelius reiterated Obama’s claims that the federal government will handle 100% of the costs of covering new enrollees in 2014, 2015 and 2016, and at least 90% in subsequent years.  However, this claim of the federal government “picking up the tab” has been under intense scrutiny.  First, no one knows where the colossal amount of money will come from, although Obama has slashed the upcoming Medicare budget by over 716 billion. Secondly, states are terrified that, once 2017 comes, the states will not be able to afford the Medicaid bill.

For states that do not decide to accept federal dollars to expand, those states will continue to receive federal funding status quo, at least from 2014 through 2016.  Those states would receive their regular federal match rate — which varies from 50 percent to 78 percent, depending on the state.  After 2016, it appears that the states could apply for federal permission for a partial expansion.
There is no deadline for states to make a decision on expansion, unlike the related decision about whether to operate a state-based insurance exchange. But states that opt-in sooner, will be eligible for increased federal funding.  No doubt the decision  on expansion will rest largely with state legislatures as they try to set the 2014 budget.
As for the decision to run state-based insurance exchanges, that the blueprints are due to the federal government Friday if the state would like to run its own state-based exchange.  As of Monday, the feds have received  formal plans from 14 states and the District of Columbia to set up their own exchanges, and that they had reviewed and approved six of them: from: Colorado, Connecticut, Massachusetts, Maryland, Oregon and Washington state.  The administration will sign off on those plans on a rolling basis.  There is no deadline by which states must declare their intentions regarding the Medicaid expansion.

According to a Forbes blog, just more than a dozen states appear certain to take part in the expansion. In about 13 states, officials have been leaning heavily against it. In the remaining states, the decisions are uncertain.  The Forbes blog has NC as uncertain.  No shock there. McCrory has only stated that he wants to research the possible consequences of expansion before making a decision.  A statement, in my mind, that shows McCrory is inclined to make an educated decision, instead via party lines.  He may also have been waiting to see whether NC could have submitted a partial expansion, but now that is not an option.

The fundamental question NC state leaders have to ask is, “Do I believe that NC will continue to get 90 percent of the cost of the expansion from the federal government perpetually, given that the federal government has no money?”