blog.timesunion.com/capitol

I submitted and published the following opinion on http://blog.timesunion.com/capitol/archives/70849/omigs-sheehan-is-leaving. As anyone who has even the least amount of knowledge of the NYS Medicaid system notes that there is nothing fabricated about it. As they say the facts speak for themselves.

1.    Retired From OMIG

June 20, 2011, 11:48 PM

Quite frankly anyone who did not see Sheehan’s termination coming should re-evaluate the strength of their monocle. I, for one, am actually surprised that under Cuomo’s regime Sheehan lasted as long as he did. I surely thought he would be out right after Cuomo’s assemblage of that grand Medicaid Redesign Team.

For those who aren’t familiar with my enormous admiration for the Medicaid Redesign team, you can read my written idolization at http://leplumefornewyorkers.blogspot.com/2011/04/who-is-really-ripping-off-nys-medicaid.html

Jim your forced resignation is nothing less than a signal that the citizens of this State have lost and the crooks have won. Hey but then that’s only my opinion, and all who know me, know how impulsive I am. After all, who in his right mind espouses the following belief: when arsonists roam the streets unchecked, don’t bother calling the fire department, step aside and watch the buildings burn to the ground.
And, really, that’s exactly what needs to happen to the New York State Medicaid Program – it needs to be completely trashed. Burned to a crisp; its ashes tossed into the coming storm and then a new system should be remolded to meet the needs of the decent few. This, of course, has implied in it that in the new form the Medicaid program be out of the reach of the politicians and in the hands of civil minded administrators —you know the type those who put the needs of the needy over those of the glutens.

For those unfamiliar with Medicaid corruption it is difficult to understand the depth of abuse and fraud that exists in the program. It simply cannot be comprehended by those who see Medicaid as a social philanthropy. The only ones who come close to seeing the depth of the abuse and fraud are those charged with trying to scoot away the vultures in a feeding frenzy.

Thirty years I had been with the Medicaid audits and investigations, under its various names, and in all those years, only under Sheehan’s leadership has the agency been able to make a slight mark on Medicaid corruption. And for this he was forced to resign.

How could that happen I ask?

It could not have been incompetence. He succeeded where others before him failed. Sheehan made the NYS OMIG. Intelligence and knowledge could not have been a factor either. The man was a Federal Prosecutor and a Harvard graduate, for God’s sake.

As I sit here contemplating the absurdity of the termination, I can’t help but realize just how influential Medicaid corruption really is. Not only has it caused the termination of Sheehan, but it is also causing the tearing down the whole OMIG organization — OMIG staff today have been advised that under: “…the Governor’s initiative to achieve cost savings…one or more positions within certain titles have been identified for reduction.”

Now doesn’t that seem just a little strange, especially since Medicaid audit titles are Federal mandated and paid for in part by federal funds?

Jim, what else is there to do? — When arsonists roam the streets unchecked all that a decent person can do is step aside and watch the buildings burn to the ground.

#The following was a reply to the above. Again as anyone with the minimal amount of information of the Medicaid program can see the reply is not exactly correct.

2.    Hold the Line

June 22, 2011, 12:08 AM

Retired, your blog/post is a little over the top. OMIG was suppose to combat fraud in identifying all those milestone amounts for CMS. Instead it concentrated on hammering legitimate providers providing much needed services to vulnerable populations–many auditor’s in OMIG seem to think that’s a crime in and itself. OMIG, by its director’s own admissions, was not designed to combat fraud–and Mr. Sheehan’s own testimony clearly indicates he didn’t care to differentiate between fraud and minor errors. That is a BIG problem. OMIG had its 15 minutes of fame. The demonstration agreement is almost over. It needs to reorganized with a new mission-to prevent improper or fraudulent billing before they happen. BTW, no OMIG titles are federal items.

#27

And as the following reply indicates I’m not the only person aware of the fallacy of “HOLD THE LINE’s” the reply.

3.    Baron Von Grumble

June 22, 2011, 11:45 PM

Hold the Line … now who’s playing fast and loose with the truth? OF COURSE there is a difference between fraud and “minor” errors. When there is a billing error, the provider must pay it back if they can’t produce the documentation to support what they billed for. Fraud is something else and carries additional fines and penalties. But if you didn’t want to hear/see that clear distinction in testimony and written statements, that’s your choice.

If you understood how Medicaid works, you would know that Dept. of Health is responsible for the ‘front-end’ of the system to try and prevent erroneous payments from being made in the first place. The system is constantly being updated but will never be perfect … which is why auditors and investigators will always be needed.

As “Retired from OMIG” correctly stated above, states are required to pursue Medicaid fraud and OMIG items are partially Federally funded.

I don’t know where you got your facts from but for your own credibility’s sake, please consider an alternative source.

I tried answering Hold the Line’s comment several times, but was unsuccessful in getting my answer published. So I’m doing the best next thing, I’m publishing it here.

Hey Hold The Line, I’m glad that Baron Von Grumble as made the point a lot  more gentle and eloquently than I have the nature of doing.

You see, I have no desire to get in a debate over what was OMIGs function. To understand the scope of the OMIG one would have to have a detailed look at past administration’s runaway Medicaid policies. And then whatever OMIGs function was, as you stated it only lasted 15 minutes. But they were the longest 15 minutes unscrupulous providers have experienced in over twenty years. If 15 minutes had them defecating bricks, can you imagine what they would have passed had OMIG lasted a ½ hour?

What I have always been amazed at is how each provider that I audited (and I audited quite a few) swore that they were providing the best “needed services to vulnerable” population. They swore they were all saints. In fact, even a NY State senator proclaimed them to be saintly.  Imagine the indecency of that in the conduct of State Business this public representative claimed that Medicaid providers are in fact “doing God’s work.” You just can’t make this stuff up.

Unfortunately, my experience has led me to conclude that, for the most part (the exception is only a handful), most Medicaid providers care more about stuffing their pockets than providing “needed services to vulnerable populations.” In fact, most of the providers who swore they were purer than snow were actually dirtier than curbside slush.

I, and those like me, care about the “vulnerable population.” We have been the ones who have cared about the level and quality of service they receive. And that is the reason why it bothers me to no end to see a bunch of vultures feeding on the “vulnerable populations”. The “vulnerable populations” you refer to are real people who for reasons beyond their control find themselves in the hands of those clad in priestly attire sucking their blood like hungry vampires. Don’t tell me Medicaid providers are providing “needed service to vulnerable populations.” Don’t even suggest it, I know better.  

You suggest a distinction between minor and major errors. Let’s see how fraud is really dealt with.  When OMIG auditors discovered fraud or potential fraud, the cases were (had to be) turned over to the Attorney General’s Office (AG). But here is the thing; the AGs office did not have to accept them. In fact, they turned down more referrals than they accepted. Some of us (I included) began to suspect that if there wasn’t a potential for a HEADLINE it did not serve AG’s scope.  We never knew this to be a fact, for us it was just an educated feeling.

As for minor problems: it’s often been said that OMIGs was a “grammar mill”: if the “ i “  were not dotted or the “t”  not crossed, the service was disallowed. There is only one answer to that it starts with a “b” and ends “t” with an “s” in the middle.

The only individuals who would say that are those unfamiliar with the internal processes of findings substantiation and those unfamiliar with the NYS Medicaid Codes or, perhaps, those familiar with the regulations but refuse to abide by them. The truth about findings is that only when a regulation is violated can the finding be processed. And the regulations can be found in the Provider Manuals, Title 18, Title 10, Title 14, Title 16 and so on. If you’re not familiar with them, give them a reading.  You’ll be amazed to find that there is no distinction between “minor and major” infractions. They are all the same!

And while we’re talking about findings how does one classify the following?

What is lack of evidence for a billed service -- minor or major?

What is claiming a patient to be HIV positive (when the lab test clearly finds them negative) -- minor or major? (And you talk about “needed service to vulnerable population.”)

What is keeping patients on the same Physical Therapy for 5, 6 years -- minor or major?

What is billing for the same patient, same service same date of service at least twice and sometimes as many as four times –minor or major.

Do you really want me to go on? We can talk about DRGs; we can talk about Diagnostic and Treatment centers, Outpatient Surgery Clinics, OASAs & OMH programs, Home Aide services.  

One final note, what I wrote was:

“Now doesn’t that seem just a little strange, especially since Medicaid audit titles are Federal mandated and paid for in part by federal funds?”

                        I never said the titles are federal items.

And for your suggestion “It needs to reorganized with a new mission-to prevent improper or fraudulent billing before they happen.” It was tried years ago, it didn’t work then and with the staff cut back it certainly won’t work now. The truth of the matter is that both approaches (Prospective and Retrospective) are needed and both need to work towards one goal -- get the vultures out of the program.  To achieve that goal the program need to be gotten out of the hands of the Department of Health. Medicaid has to be an independent entity with its own elected director – much like the State Comptroller’s Office.  As long as politicians have a hand in it the “needed services to vulnerable populations” is just talk.

So if I seem “a little over the top” to you, don’t despair. I assure you my bottom is well grounded (as well as well rounded).  If it weren’t, there are at least several providers who would surely place me on a monthly colonoscopy plan. -- If only they could bill Medicaid.

Two Years Later ... Still Unbelievable

To understand my next blog, you must first read the following: http://www.nynp.biz/freatures/1704-the-omig-who-stole-xmas

Now I know this was published almost two years ago. And that answering it such a long time after its original publication may seem outdated and one might ask what's the point?

The point is if X-mas was stolen as the article states, then let's see who really stole it?

Politicians, and Medicare

During the past several months there has been an intense political discussion about Medicare.  Mostly, the spat revolves around service cuts.  One side wants a great number of reduction, the other just a few. Very few “representatives of the public” (senators, congressmen, and even the president) talk about no reduction at all.

But mostly they all want to slash services. 

I’m not a public representative; I’m a working class slob, so I want not cuts at all. In fact, I favored universal healthcare long before we even had a name for it. And here is the thing (there’s always a thing isn’t there?) the results of most studies from the mid-eighty of the past century indicate that the majority of Americans want universal healthcare. One study actually reported that 80% of the Americans favor “universal healthcare.”

So why don’t we have it? Is America not a democracy? God!  Isn’t the “majority rules” principle the most basic code of our nation? Isn’t this basic concept the very heart of our Declaration of Independence? Doesn’t our most sacred document begin with—“We the people….”?

Well then?  If the essence of democracy is majority rules, could it be that we are really not a democracy?

What does this have to do with Medicare? You see folks; this is all related, but the why, and the how, and the when, and the where, and the what is too long of discussion to present here. I would like for you to just accept the premise that America is a democracy only on paper in reality it is ruled by an “interest” that is not always the voice of the majority. Especially, when, it comes to the wellbeing of the working people like us. Medicare, Universal Healthcare, Social Security, and yes, at times, even Medicaid exists to do good to the working class. But those whose interest is not that of the working class would tell you otherwise.

They want you to believe that Medicare and Social Security are entitlement programs; programs that are fundamentally used to redistribute wealth programs. They want you to believe that these two programs Medicare and Social Security are almost bankrupt. These are lies!

These are outright lies! Medicare and Social Security are not near bankruptcy, they are not wealth redistribution programs and they are absolutely not entitlement programs.

You pay for them! You pay for them all your working life. You don’t believe me; look at box number 6 of your W-2 form. Look at your self-employment tax computations.

We are paying for Medicare and are forced to do so. You don’t believe this, try refusing to pay into social security system, try refusing to pay Medicare.

You and I and every individual that works or worked for a living have had a portion of our income taken to fund these programs. And as for Medicare, all of our working life we have been forced to pay so that when we’re 65 year old we can apply for Medical coverage. Yes folks we have to apply for Medicare, it’s not automatic like the payments we make. Then after applying and being accepted we will have to further pay another $98 per month. Is this an entitlement program?  And some will claim the government should not be forcing the people to buy Medical coverage. But the Government is forcing people to buy Medical coverage. What does anyone think Medicare is?

We are forced to pay all of our working lives something like 30 to 40 years, to get coverage for something like 20 years. (The life expectancy is 77.4) We contribute 30 to 40 years for nothing, and then when we enroll to get something, we have to continue to pay. And on to top of it all our representatives (the folks we elected to do our talking for us) want to slash coverage.

Where is the sanity in this?

For a more basic way of understanding Medicare, view it as a lay-away plan where you pay for an item for thirty to forty years. Then, when it is time to pick up the article you have been paying for, the store clerk tell you,  “The item you have been paying for has been slashed.”

Is this not madness!  Is this not an insanity forced on us by the very people we have elected to supposedly maintain “a more perfect union”? Furthermore reason tells that when one pay for something, it is not an entitlement program; it is not a wealth redistribution program. It is a business transaction where there is a seller (the government) a purchaser (you and I) and a service (medical coverage) changing hands at a price.

Now don’t misunderstand the message: I’m not against the government running Medicare. Government is the only entity that can run Medicare. The privatization of Medicare, of Social Security of Medicaid (even of Universal Healthcare) is millions of times worse. Remember Enron; remember the bank crisis, (so far in less than 30 years we’ve had two); the mortgage meltdown; the auto industry. If you (pardon the French) feel that government Fu-- us, private industry goes one step worse it rapes us, without Vaseline.

The problem is not government, the problem is the representatives who when it comes time to vote speak one message (they represent our interest), then after the election they represent the interest of others.  And those others (as I pointed out in the previous Blog) are those who are really ripping off the system.

Medicare like Medicaid is fraught with thieves, many who have the ears of the elected official who care little about the voice of the people and a lot about their own pocketbooks.  Should not in a democracy, the voice of the people be the voice of government?

[By the way, just to keep things in perspective, the concept of the people voice being the rule of nation is not an original concept. Democracy can be traced back to at least Ancient Greece, and the Roman’s actually had a motto:  Vox populi, vox Dei, which loosely translates to: the voice of the people is the voice of God.  Jesus, those damn Romans! If only they had had a good fire-department; we’d all probably be speaking Romanese. (Oops, sorry about that folks, there’s no such language as Romanese; it’s really called Italic, a derivative of Eyetalian.)]

But the point is not what language we’d be speaking; the point is that those whom we have elected to speak for us are speaking a whole different language. In their language Medicare is an entitlement program; Medicare is a wealth redistribution program and Medicare is near insolvency.

 This, in case you missed it above, are lies … outright lies.

Medicare is a bought and paid for healthcare program without any valid reason to be slashed. If it lacks liquidity which is different than insolvency, then it should call in the IOUs. And no one can deny that Medicare and Social Security are abounding in IOUs, some of which date back to the Vietnam era.

The surpluses that existed in the programs {the revenue (Our contributions) in excess of the expense (the benefits paid)} has been used in part to fund the wars beginning with Vietnam all the way to the Iraq invasion. In addition, the surpluses have also been used, in part, to fund our representatives’ pet projects. Overall the surpluses have been used like a store system where one walks in hands over an IOU and walks out with our cold hard cash.

It’s not the benefits that need to be slashed; it’s our representatives that need to be reminded of whom they work for.  (They work for us, not the American Medical Association, not Metropolitan Life, not Pfizer.) They work for you and me.

Enough already! It’s time to make our voices heard. Contact your representatives (every one of them, local, state, federal) and tell them Medicare and Social Security is no to be touched.

Who is Really Ripping off NYS Medicaid

S’io credesse che mia risposta fosse
A persona che mai tornasse al mondo,
Questa fiamma staria senza piu scosse.
Ma perciocche giammai di questo fondo
Non torno vivo alcun, s’i’odo il vero,
Senza tema d’infamia ti rispondo.*

I do not know if I am the only one in State of New York who thinks this way. But I want to believe that among the 18 million people or so there is at least another. There just as to be at least one other person who finds Governor’s Cuomo Medicaid Redesign team an insult to what is decent and righteous in New York. 

Twenty seven people redesigning Medicaid -- not one person from the New York State Medicaid Audit and Investigative body; not one individual who has any first-hand experience dealing with the grimy business of Medicaid Fraud and Abuse. And believe me, it is a dirty business: a 54 billion dollar a year filthy business with an estimated 5.4 billion in outright fraud and another 11 billion to 20 billion in abusive practice.

If you don’t find that grimy; … well, what can I say? … Let’s just leave it at that. Still, though, make no mistake about it; the Medicaid Industry in New York State is fraught with thieves.  The worst types of thieves! – Thieves that steal with impunity and with an ingrained belief that they have the absolute right to embezzle from the public treasury.   They are worse than the street muggers; worse than the bank robbers; worse than the unprincipled financiers. These are thieves who use the infirm, the invalid, and the unfortunate to stuff their pockets. To  them, sick people, young and old, male and females, alive and dead are nothing more than a commodity, a means of milking a system that was established to assist those who have no place else to turn.

But don’t blame this scum! If you really want someone to blame, don’t walk too far from you own toilets. Look in your vanity mirrors and you’ll find the real culprits. You are to blame; you and me, and all the others who, instead of demanding a just government, simply stand by and allow unscrupulous politicians to favor those who contribute to their campaigns.

How dare I make such bold statements? Never mind that I’m allowed to do so by the Constitution. (You know that part about freedom of speech and stuff like that.) I am someone who spent thirty years working as a New York State Medicaid Auditor. I am someone who started as a trainee and climbed to mid-level management. I am someone whose lips would not have quivered, had this State’s Medicaid system not become a manger where pigs feed.

 It just too much for anyone in the know to sit idly by without commenting. Just too much!

Now let’s be clear about something, not all Medicaid providers are thieves of course, but just enough of them to give validity to the statement. They are heartless, not all of course, but just enough of them to make you worry about your afflicted neighbor, siblings, mother and grandmother, father and grandfather, sons and daughters, whom might have no other alternative but to visit Medicaid mills, clinics, or other types of Medicaid facilities.

Beware! Don’t trust them for one heartbeat! They may portray themselves as saviors, but they are in reality more ravenous than blood hungry vampires.   Not all of course, but just enough of them!

If I seem angry, I am. And if you are not angry after reading what follows, then truly the words inscribed above the portal of hell should be carved on the gates of New York State: Abandoned of hope yeah who enter here. ( Dante’s Devine Comedy)

If you still are not angry after reading this, then what in hell is wrong with you? But if you are, even in the least possible way, get up off your asses and do something: call you State Representatives and tell them you’re against the Medicaid Redesign Proposals.  What you want instead is more provider accountability.

In this first presentation let’s start with latest Medicaid farce.

 The Medicaid Redesign Team

Who are they?

Recognizing who they are can give an idea of whose interest they uphold. 27 people, not one representing the welfare of Medicaid Recipients or the welfare general public.  —  Not one!

Representing Healthcare Workers             2

·         Former Chair of SEIU Healthcare and currently the Senior Advisor to the International President of SEIU.

·         President of 1199 SEIU United Healthcare Workers East

Representing Medical/Healthcare Provider Association              7

·         Healthcare Association of New York State.

·         President of the New York State Nurses Association

·         President of the Community Health Foundation of Western and Central New York.

·         Executive Director of the New York State Association of Counties.

·         Former Chairman for the Commission on Health Care Facilities in the 21st Century and a board member for the Partnership for New York City.

·         CEO of the Community Health Care Association of New York State.

·         President of the Greater New York Hospital Association.

Representing Direct Providers       5

·         President and CEO of North Shore LIJ Health system.

·         President and COO of Emblem Health.

·         CEO of the Metropolitan Jewish Health System as well as the Chairman of the Continuing Care Leadership Coalition.

·         President and CEO of the Visiting Nurse Service of New York.

·         CEO of the United Cerebral Palsy of New York City as well as the President of the Interagency Council.

Representing healthcare Institute and Councils 2

·         Co-Chair of the JFK Jr. Institute for Work Education at City University of New York.

·         Chair of the New York State Public Health and Health Planning Council.

Former Advocates for providers 1

·         Coordinator at Medicaid Matters New York (a prior advocate for the Mental Health Provider Community).

Elected officials 5

·         Senator

·         Senator.

·         Assemblyman.

·         Assemblyman.

·         Deputy Mayor of New York City for Health and Human Services

Quasi Elected Officials 5

·         Commissioner of Health.

·         Commissioner for the Office of Mental Health.

·         Commissioner of the Office for People with Developmental Disabilities.

·         Commissioner of the Office of Alcoholism and Substance Abuse Services.

·         Deputy Secretary for Health and the Director of Healthcare Redesign.

What have they recommended?

This prestigious group of people received over 4 thousand suggestions on how to “reduce the cost” of Medicaid in New York State. They selected 79.

I am not going to comment too deeply on the directions for submitting suggestions.  It suffices to say that one had to make ones case in 2 minutes. Depending upon one’s ability to rapid-speak the limit was set to a maximum of 500 words. 

Appreciate that for a second! Roll it over in your minds! Let it linger there and then try presenting a potential solution for the restructuring of a 54 billion dollar per year industry in two minutes. 

God, that is exceptional!

And even more fantastic is that of 4000 recommendation 79 were so superior to the others that they merited recommendation.  

Let’s examine some: 30 (38%) neither decrease nor increase (if you can believe that) the cost of Medicaid; 6 (8%) will cost money to implement, and the remaining 42 (53%) are supposed to reduce costs. (The total percentage equal 99 because of rounding)

As a matter of substantive analysis the reduction of costs is a hopeful dream, at best. Recommendation number 131, for example, with an estimated savings (208.50 million) is nothing more than a way for providers to increase their own profits at the expense of impaired infants and the Medicaid system.

As the “Short Title” indicates, this recommendation is a backhanded way for providers to reduce the amount they pay in malpractice insurance. From a simple accounting perspective the less expenses paid, the greater the bottom line.  And here comes the tragedy the proposal focuses on - the “neurologically impaired infant….”

It makes no reference to children born with deficiencies. The proposal’s implied aim is at those infant that have been afflicted.  It refers to defects imposed through failed or improper procedures! It stands to protect provider’s incompetence or outright malpractice.

This recommendation then is a direct assault on everyone because providers would be able to get away with maiming infants without repercussions.

But recommendation 131 is only part of the whole farce. The overall essence of the recommendations is to enroll the majority of Medicaid recipients with chronic conditions in Managed Care. To those who do not understand the finer points of Managed Care, this may seem a viable way to reduce cost. The fact is, however, that Managed Care makes a few ultra rich while the many receive low standard treatment. 

Under the Medicaid system there are only two ways for a provider to receive payment: fee for service and managed care. The question that needs to be examined then is how providers earn under these two systems. In the fee-for service the issue of making money is quite simple: a provider makes money by receiving payment for services rendered … more services, more money; no services, no money. Under the Managed Care system, money is made in just the opposite manner: fewer services, more profits.

To understand Managed Care one needs to be familiar with the capitation system which is a scheme that pays a set amount per person whether that patient is treated or not. To repeat this in another way: the provider gets paid regardless of whether they provide services or not. More services does not equate to more money, in fact more services actual amount to less profit. So a Managed Care provider’s goal is to enroll as many patients as possible and provide as few services as possible. Enroll many provide few services, that’s the profit motive of Managed Care.
It gets even more odious. Managed Care does not only affect the patient. For the independent practitioner (your local doctor or local clinic) the situation is no better. To receive Medicaid funds the local practitioner must become a member of a health maintenance organization (HMO) and in New York State there are only 39 such organizations. Your local doctor has to either enroll with one of them or forgo Medicaid reimbursement.
Thus the reason why patients should resist Managed Care is obvious; they stand to get little or substandard service. The reason the local doctor and clinics should resist managed care is that they will likely get the patients who are in need of the greatest amount of services at no greater reimbursement.
In conclusion under Managed Care not only do the patients suffer, but so do the small providers.

Proposal 18’s short title is Eliminate Spousal Refusal.
In essence this is mostly applicable when an individual needs to be placed in a long term facility (nursing home).
Nursing homes have ranked among the top Medicaid abusers for decades. One of their tactics for stripping individuals of their savings is as follows: when the individual has money the nursing home charges them the “private pay rate”, which is substantially higher then what Medicaid pays. Usually the individual nest egg is exhausted anywhere between 6 months to a year. When all of the individual’s money is gone, the nursing home helps the individual enroll in Medicaid. This practice has been going on for as long as there have been nursing homes.
As a result many astute spouse and family members have refused financial support for their loved one in nursing home. While nursing homes, the politicians they bought and the media accuses these folk of being selfish, they are truly not. It has nothing to do with love; it has to do with survival. By accepting financial responsibility, the nest egg accumulated through a working life is basically hoarded by the nursing home in less than a year. And then after the total exhaustion of the individuals savings instead of having one person on Medicaid the spouse and the other member of the family will have to be enrolled.    
According to the Redesign Team, each recommendation falls into one of 7 “Themes.” By “Themes” these greatly-civil-minded individuals mean the expected results.

38        proposal are expected to “Recalibrate Medicaid Benefits and Reimbursement Rates”

The majority of these involve moving patients into Managed Care Programs. We’ve already discussed raising profits by diminishing services.

15        proposals are expected to “Eliminate Governmental Barriers to Quality Improvement and Cost”

The elimination of Governmental Barriers to Quality Improvement and Cost is just another way of saying eliminate governmental supervision of programs. In another word, get rid of the watch-dogs. I’ll leave it to your imagination what happens to service when no one is looking. If you lost your home, if you’re unemployed, if you can’t buy gas to run your car, if your retirement plans have gone up in smoke you are the direct result of deregulations.

9          proposals are expected to “Ensure Consumer Protection and Promote Personal Responsibility.”

Another way of saying it’s your fault for getting sick.

Eliminating Governmental Barriers eliminates Consumer protection. When governmental barriers are eliminated the individual consumer simply does not have the strength to stand up to the providers.

The individual consumer lacks the money, the know-how and clout to oppose the providers.

Three quick examples: the 60 month look back period for transfer of assets to non-institutional long-term care applicants with spousal impoverishment protections. And “Add Consumer direct Personal Assistance program (CDPAP) services to managed long term care plan packages.

 A third proposal would give statewide responsibility for making Medicaid Recoveries from the estate of deceased recipients, in personal injury action and in legally responsible relative’s refusal cases.

The great thing about this proposal is that it expands state authority (and eliminates a Social Services Regulation already established) but the direction favors providers.

7          proposals expected to “Ensure That Every Medicaid Member is Enrolled in Care Management”

“Déjà vu all over again.” Managed Care once more.

7          proposals are expected to “Empower Patients and Rebalance Service Delivery”

            Just look at the recommendation!

2          proposal are expected to “Eliminate Fraud and Abuse”

Of the 79 proposals only two are dedicated to the elimination of fraud and abuse.

One just has to admire this.

CMS the former HHS which is the federal agency that runs and administers Medicare and Medicaid have stated that a conservative estimate of Fraud and Abuse in the Medicaid program is 10%. Other have agreed,  and have stated that along with the 10% fraud rate there is likely to be 20 to 30% abuse in Medicaid thus the real percentage of fraud and abuse in Medicaid varies somewhere between 10% to 40%. (Look this up folks don’t take my word for it.)

When actual calculations are applied one finds that in dollar value Fraud and Abuse in New York State is somewhere between 5.4 billion to a possible 22 billion dollars. Even using the low figure of 5.4 billion one must admit that it is a lot of money being stolen.

Considering that hardly any part of this money ever gets into public hands or is used to assist the infirm, one can’t help but conclude a few people are getting awfully wealthy stealing public funds.

Doesn’t it make sense then if one were getting rich with public funds wouldn’t one want fewer regulators over your shoulders? Does a street-thief want a cop on every corner?

That’s the reason why of 79 proposal 15 want to eliminate governmental intervention and only 2 want to eliminate fraud and abuse. It clears the way for pigs to run to the manger.

1                    proposal is expected to “Better align Medicaid with Medicare and ACA”

My objective is not to provide a full analysis. That would take too long. I just wanted to present a few points and show how the proposals are actually slanted to favor the providers (the large ones) over the people (you and me).
Recommendation
Along with criticism there has to be a sound alternative. Thus, how would someone in the know solve the NYS Medicaid problem?
The first recommendation is, of course, to get rid of the pigs in the system:  exclude them, sanction them all that is required is a 45 day notification. And that does not mean to shut down services, it means to replace the bad managers with those who are civic minded
The second is reevaluating the guiding principles of the New York Department of Health, with the OASAS, with OMH with OMRDD. Their policy, written and unwritten, are the greatest causes of problems in the NYS Medicaid system. You know the one that favor providers over patients.
Another proposal is to extract the Medicaid program from the hooks of the Department of Health. You simply can’t have the wolf guarding the chicken coop. While federal law requires that Medicaid be administered by overall agency. It does not have to be one that makes Medical policies. Medicaid should be independent body. It accounts for 54 billion dollars a year, why does it have to be affiliated with those who make provider policies.  
I have only skimmed the surface as a way of introduction other topics will be covered in future discussion. One such analysis will be how some organizations have captive audiences and use them as a means to exploit the system, through DOH, OASAS, OMH, OMRDD services that many times simply duplicate each other.  
Another of my favorite topics is the way providers are granted Operating Certificates (licenses to operate.) As a way of introduction: Several years ago there were so many Operating Certificates issued for a particular types of health clinics that no one in the Department of Health knew how many of these Medicaid mills actual existed. (Remember the part-time clinic project.)

But don’t worry folks no names will ever be mention; well except for that politician who had the nerve to claim in public session that Medicaid Providers are doing God’s Work. That gentleman’s name must be made known. ‘cause we all need to ask which deity he is talking about -- Mr. J. does this deity’s name begin with an S?

No names, but I assure you that what I will tell is factual and traceable either to some periodical or some internal audit investigative document, which can be gotten through the Freedom of Information Law (FOIL) before they are “sanitized”.

Why sing?

Because I’m just f---ng fed up, with the b-ll--it, a few getting fat while over 3 million kids in NYS go hungry every single day. … This is not America! This is more Baghdad than New York, but at least the Iraqis have an excuse, - they have been devastated by war. What’s our excuse? ...  the few gorging off the misery of the many.

* From Dante’s Hell

If I believed that my answer would be to someone who would return to the world, this flame would never quiver, but because, if I hear the truth, from this hole no one has ever returned alive then without fear of infamy I shall answer.