In both rural and urban areas, the Colorado Health Access Survey found that insufficient numbers of dental providers participate in the Medicaid program, so despite an increase in the number of children who had dental insurance, fewer actually visited dental providers. An additional 66,300 children had dental insurance in 2011 compared to 2009.
Video: Boston: Medicare Fraud Summit Providers Panel
Cuts to California Medicaid could hurt reform, providers say
Chris Perrone, a deputy director at the California HealthCare Foundation, a not-for-profit health policy group, said California already has very low payment rates compared to other states, and some findings suggest that access is already poor. One study found that California reimburses primary care physicians an average of 53% of Medicare, the federal healthcare program for seniors, he said. According to the state Department of Health Care Services, Medi-Cal pays $24 for a 15-minute visit to the doctor’s office. By comparison, Medicare would pay roughly $70. Some Democratic lawmakers want the state to rescind the cuts approved last year. At the time it was passed, AB 97 was projected to save $660 million, with half the savings going to the state’s general fund. “We’re now in a much different environment than we were when we first made those cuts, so given the opportunity, I would like to see those restored,” said Sen. Ed Hernandez, a Democrat from Baldwin Park and chair of the Senate Health Committee. The federal healthcare law seeks to increase health coverage by 2014 by creating new online insurance markets for individuals and small businesses to shop for subsidized private coverage, and by expanding Medicaid for low-income people. Medicaid is known as Medi-Cal in California and currently serves 7.7 million adults and children. Gov. Jerry Brown has not said whether California will commit to fully expanding its Medi-Cal program to take advantage of federal funding. Under an expansion, Medi-Cal would cover people up to 138 percent of the federal poverty line, or about $15,400 for an individual. It’s estimated such a move would add between 1 million and 1.4 million people to Medi-Cal. The state is also in the process of moving 900,000 kids from the children’s health insurance program known as Healthy Families to Medi-Cal. “The court decision does not change the state’s commitment to ensure access to healthcare for Medi-Cal members in a manner that fully complies with federal and state law,” said Norman Williams, a spokesman for the state Department of Health Care Services. More than 400 hospitals and about 130,000 doctors, pharmacists, dentists, and other health care providers participate in the Medi-Cal program. However, the state doesn’t track whether some of them have stopped accepting new Medi-Cal patients or limit the number of patients they take. “If you’re going to set payment standards for pharmacies and for the other providers which are below their cost, and they won’t provide services, then all those millions of people coming into Obamacare in California are going to get third-world medicine,” said Lynn S. Carman, an attorney for a group of pharmacies. Carman said his group intends to file an appeal next week seeking to be heard by the full court, not just the three-member panel in the 9th U.S. Circuit Court of Appeals that ruled Thursday. Molly Weedn, a spokeswoman for the California Medical Association, which represents 35,000 doctors, said it’s expected that the 10% cut won’t take effect while health providers pursue their legal challenge. But Brown’s finance officials have indicated the state expects to see additional savings by having the cut applied retroactively to June 2011. The doctors group warned that if the cut is upheld, many physicians will have little option but to stop taking qualified patients because the reimbursements do not meet the cost of overhead and supplies to treat them. Faced with multibillion budget deficits in recent years, the state Legislature already approved a series of Medi-Cal benefits cuts, some of which are still awaiting federal approval. For example, the state has cut dental care for adults and weeded out services such as podiatry, psychiatry and optometry. Health reform does bring a glimmer of hope to California’s low reimbursement rates. Primary care providers are expected to receive a temporary two-year payment boost under the federal health care law to match Medicare rates. But California will only get the boost if it maintains its current rates, said Anthony Wright, executive director of Health Access California, a group that lobbies for healthcare for the poor.
OIG Report Poses Potential Problems For Medicare Providers
According to the report, providers (physicians, suppliers, hospitals, etc.) filed 85% of all Medicare appeals in 2010; beneficiaries accounted for 11%; and state Medicaid agencies accounted for the remaining 3%. Furthermore, a small number of providers accounted for the majority of appeals. For example, one provider appealed over 1,000 claims, whereas the average provider appealed 6 claims. Additionally, ALJs reversed 56% of all prior-level decisions at appeal, in favor of appellants. Reversals were highest for Part A providers – 62% (hospital appeal reversals were 72%). Reversals for Part B providers were 59%; DMEPOS suppliers were 53%; Part C providers were 18%; and Part D providers were 19%.
State Roundup: Report Finds Racial Gap in Colo. Dental Coverage; Health Cuts Part Of Conn. Budget Plan
CT Mirror: Malloy Defends His Plan To Collect More Revenue From Businesses Gov. Dannel P. Malloy defended his plan Monday to seek an extra $22 million in revenue from businesses and power plants to help close the current budget deficit, arguing this doesn’t break his pledge not to raise taxes. … Though details were limited, the “road map” — as referred to by the administration — called for $220 million in spending cuts and $22.6 million in new revenue. … Malloy also acknowledged he could face a tough road with his fellow Democrats in the House and Senate majorities. The largest single-reduction proposed Friday involves $122 million aimed at the Department of Social Services, which administers a wide array of health care and other support services for the poor, aged and disabled, most of which are partially supported with federal aid. That proposed $122 million cut is expected to save the state just $63.5 million since the reduction would trigger a $58 million loss in federal assistance (Phaneuf, 12/10).
First Choice News: 9 Health Care Providers Charged With Medicaid Fraud In NC
Raleigh, N.C. – Nine health care providers in five North Carolina counties were charged Tuesday in the state’s continuing crackdown on Medicaid fraud, authorities said. The suspects – a dentist, home health care workers, a mental health care provider and an HIV case manager – are accused in various schemes that netted about $200,000 in fraudulent payments, according to Attorney General Roy Cooper. State Bureau of Investigation agents made the arrests in Wake, Cumberland, Dare, Alleghany and Sampson counties, and authorities said more were expected in the coming weeks. A Medicaid fraud sweep last December resulted in 20 arrests. Seventeen of those suspects have been convicted, and two more are awaiting trial. “We’re continuing our crackdown to deter those who would commit health care fraud,” Cooper said. “Cheating Medicaid is illegal, and our investigators and attorneys are finding violators and making them pay.” The suspects arrested Tuesday include: Gloria Sawyer, HIV case manager, Wake County. Sawyer, owner of I Believe in Miracles, is accused of concealing her felony drug convictions when she applied to be a state Medicaid provider. Authorities said she received more than $100,000 for her services to Medicaid recipients. Sawyer is charged with three counts of obtaining property by false pretenses and two counts of obtaining property by false pretense. Kellie Hickman, home health care aide, Sampson County. Hickman is accused of submitting false timesheets for care she did not provide to two Medicaid recipients while she worked for United Home Care Inc. The state estimates the loss at $2,932.50, which United Home Care Inc. has already reimbursed. Hickman is charged with two counts of medical assistance provider fraud. Dr. Francis Bald, dentist, Dare County. Bald, who owns practices in Nags Head and Elizabeth City, is accused of billing Medicaid for extra dental procedures he didn’t perform or were unnecessary. The state estimates the loss at more than $3,180. Bald is charged with medical assistance provider fraud and obtaining property by false pretenses. James Tillman, mental health provider, Cumberland County. Tillman is accused of falsely representing his educational qualifications in order to provide mental health services. Authorities said he wrongly received more than $74,000 in Medicaid payments for his services. He is charged with three counts of medical assistance provider fraud, three counts of obtaining property by false pretenses and two counts of falsifying documents issued by a postsecondary education institution. Deborah Aroche, Tammy Atkins, Michelle Bottomly, Jessica Cook, Amy Lyall, home health care aides, Alleghany County. The women, who were employees of Families First Home Health Care, are accused of submitted false timesheets for personal care services they did not provided. The state estimates the loss at more than $21,000. They are each charged with medical assistance provider fraud. The Attorney General’s Medicaid Investigation Division nearly doubled in size last year to take on more cases. The team of attorneys, investigators, crime analysts and support staff investigate fraud and abuse of Medicaid benefits by patients, health care providers, pharmaceutical companies, ambulance services and others. Cooper said the division has recouped more than $500 million in the past decade and secured convictions for hundreds of suspects. http://wral.m0bl.net/w/news-top/story/80862565/
The business behind dental treatment for America’s poorest kids
Kool Smiles does far more crowns than average on children age 8 and under on Medicaid, according to an analysis of 2010 Medicaid data in two states done by CPI and FRONTLINE. In Texas, a child under the age of 9 at Kool Smiles has nearly a 50-50 chance of getting a crown as a restoration to treat problems like cavities, our analysis found. That compares to a one in three chance on average at other providers. And in Virginia, a child 8 or under on Medicaid going to Kool Smiles is twice as likely on average to get crowns than at other dental offices.