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Attorney General investigating provider fraud in Medicaid waiver

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Attorney General investigating provider fraud in Medicaid waiver

The Mississippi Attorney General’s Office is investigating whether a behavioral therapist provider bilked Medicaid under a special program for people with intellectual and developmental disabilities.

Natalie Gunnells, the mother of a 23-year-old Medicaid recipient named Patrick, first noticed a billing discrepancy in early 2022 after requesting to see records from the Mississippi Department of Mental Health.

The Department of Mental Health administers the program, called the Medicaid IDD waiver, but the Mississippi Division of Medicaid pays for it.

Under the waiver, Patrick is eligible to receive over 200 hours of services each month, but in the last several years, he’s received just a handful of hours, if not zero.

READ MORE: ‘You’re not in line’: Family battles politics, indifference, and suspected fraud in federal health care program

That hasn’t stopped Mississippi Behavioral Services, a clinic in Southaven owned by Vargas Clark, from billing Medicaid for thousands of dollars worth of therapy for Patrick, records obtained by Mississippi Today show.

Clark, who has not been charged with a crime, said he was unaware of the investigation and did not return several follow up calls and texts from Mississippi Today. Gunnells estimates Medicaid reimbursed the company for $42,000 worth of services that her son didn’t receive from 2020 to 2022. She says disregard at the mental health and Medicaid agencies allowed this to continue unnoticed.

“We provide services as written for the service authorization,” Clark said. “Now there may be individuals that are authorized for, let’s say, 30 hours. We may be providing 10. But we only bill services for services that are actually rendered.”

Mississippi spends about $125 million annually on the waiver program, an average reimbursement of about $45,000 worth of services for each person.

Several parents who spoke to Mississippi Today and voiced their concerns at a recent public hearing want to know where all that money is going. It’s hard for them to believe that much care is being delivered, considering the worker shortage that has left them without any help for their adult children.

And they’re worried that a lack of oversight in the program could mean taxpayer dollars are flying out the door of Medicaid while some of the state’s most vulnerable residents go without services.

“There’s no telling how much fraud is occurring,” Gunnells said.

One of those parents is Deb Giles, who has been unable to find a specialist to provide the speech therapy her son is qualified to receive. But at the hearing in February, Giles focused her concerns on the accountability within the program.

“My recommendation for the Department of Mental Health is to provide the recipients with reports on audits of the providers and to provide more audits,” Giles said. “I’ve run into roadblocks, and not enough information as to how these providers are being audited. Some are not providing the services that they’re being paid for, or reimbursed for, and I would like to see more information for Mississippi on how these providers are being audited. And also I’d like to be able to assess the audits, to read throughout the state of Mississippi what the providers are providing for the recipients.”

Giles told Mississippi Today she wasn’t alleging a specific instance of fraud, but that the waiver program doesn’t collect enough information from providers to ensure they’re performing all the functions they’re supposed to.

The Department of Mental Health’s primary role in the IDD waiver is to provide clients with support coordinators from the agency’s regional IDD centers. The support coordinator’s job is to consult with the parent or guardian of an individual on the waiver to ensure they are receiving the services outlined in the support plan they create together. For years, Gunnells said her support coordinator did not review service reports with her. Several call logs Mississippi Today reviewed confirmed that this wasn’t happening.

“It seems every standard put in place to ensure appropriate care for P (Patrick) was totally ignored from the Support Coordinator to all his superiors charged with ensuring the documents such as Quarterly Reports, Behavior Support Plan and required IDD service notes were submitted on time and accurate,” Gunnells wrote in a timeline of the alleged fraud. “They were so negligent that any agency billing Medicaid, that wanted to commit fraud, could without detection.”

Patrick Gunnells, 23, watches videos on his iPad in the living room at his Tupelo home on Mar. 9, 2023.

Department of Mental Health Director Wendy Bailey said the agency conducted its own internal investigation into the matter and referred it to Medicaid. She said DMH is providing additional training to support coordinators and looking at ways to improve its site visit process at the regional centers. The central office reviews a sample of support coordination records monthly.

The state Medicaid agency is in the process of renewing its application to the federal government for the waiver.

“While we don’t have evidence to believe this type of provider fraud is widespread, we still have to be open to new ways of preventing fraud and be aggressive in rooting it out,” Medicaid spokesperson Matt Westerfield said in a statement to Mississippi Today. “This year, the Division plans to implement an electronic system for the ID/DD waiver that documents the time certain ID/DD services begin and end.”

The Medicaid statement also encouraged anybody who suspects Medicaid fraud to notify the agency here.

The Attorney General’s Office, which began its investigation more than six months ago, did not respond to several requests for comment for this story.

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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Mississippi Today

On this day in 1997

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mississippitoday.org – Jerry Mitchell – 2024-12-22 07:00:00

Dec. 22, 1997

Myrlie Evers and Reena Evers-Everette cheer the jury verdict of Feb. 5, 1994, when Byron De La Beckwith was found guilty of the 1963 murder of Mississippi NAACP leader Medgar Evers. Credit: AP/Rogelio Solis

The Mississippi Supreme Court upheld the conviction of white supremacist Byron De La Beckwith for the 1963 murder of Medgar Evers. 

In the court’s 4–2 decision, Justice Mike Mills praised efforts “to squeeze justice out of the harm caused by a furtive explosion which erupted from dark bushes on a June night in Jackson, Mississippi.” 

He wrote that Beckwith’s constitutional right to a speedy trial had not been denied. His “complicity with the Sovereignty Commission’s involvement in the prior trials contributed to the delay.” 

The decision did more than ensure that Beckwith would stay behind bars. The conviction helped clear the way for other prosecutions of unpunished killings from the Civil Rights Era.

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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Mississippi Today

Medicaid expansion tracker approaches $1 billion loss for Mississippi

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mississippitoday.org – Bobby Harrison – 2024-12-22 06:00:00

About the time people ring in the new year next week, the digital tracker on Mississippi Today’s homepage tabulating the amount of money the state is losing by not expanding Medicaid will hit $1 billion.

The state has lost $1 billion not since the start of the quickly departing 2024 but since the beginning of the state’s fiscal year on July 1.

Some who oppose Medicaid expansion say the digital tracker is flawed.

During an October news conference, when state Auditor Shad White unveiled details of his $2 million study seeking ways to cut state government spending, he said he did not look at Medicaid expansion as a method to save money or grow state revenue.

“I think that (Mississippi Today) calculator is wrong,” White said. “… I don’t think that takes into account how many people are going to be moved off the federal health care exchange where their health care is paid for fully by the federal government and moved onto Medicaid.”

White is not the only Mississippi politician who has expressed concern that if Medicaid expansion were enacted, thousands of people would lose their insurance on the exchange and be forced to enroll in Medicaid for health care coverage.

Mississippi Today’s projections used for the tracker are based on studies conducted by the Institutions of Higher Learning University Research Center. Granted, there are a lot of variables in the study that are inexact. It is impossible to say, for example, how many people will get sick and need health care, thus increasing the cost of Medicaid expansion. But is reasonable that the projections of the University Research Center are in the ballpark of being accurate and close to other studies conducted by health care experts.

White and others are correct that Mississippi Today’s calculator does not take into account money flowing into the state for people covered on the health care exchange. But that money does not go to the state; it goes to insurance companies that, granted, use that money to reimburse Mississippians for providing health care. But at least a portion of the money goes to out-of-state insurance companies as profits.

Both Medicaid expansion and the health care exchange are part of the Affordable Care Act. Under Medicaid expansion people earning up to $20,120 annually can sign up for Medicaid and the federal government will pay the bulk of the cost. Mississippi is one of 10 states that have not opted into Medicaid expansion.

People making more than $14,580 annually can garner private insurance through the health insurance exchanges, and people below certain income levels can receive help from the federal government in paying for that coverage.

During the COVID-19 pandemic, legislation championed and signed into law by President Joe Biden significantly increased the federal subsidies provided to people receiving insurance on the exchange. Those increased subsidies led to many Mississippians — desperate for health care — turning to the exchange for help.

White, state Insurance Commissioner Mike Chaney, Gov. Tate Reeves and others have expressed concern that those people would lose their private health insurance and be forced to sign up for Medicaid if lawmakers vote to expand Medicaid.

They are correct.

But they do not mention that the enhanced benefits authored by the Biden administration are scheduled to expire in December 2025 unless they are reenacted by Congress. The incoming Donald Trump administration has given no indication it will continue the enhanced subsidies.

As a matter of fact, the Trump administration, led by billionaire Elon Musk, is looking for ways to cut federal spending.

Some have speculated that Medicaid expansion also could be on Musk’s chopping block.

That is possible. But remember congressional action is required to continue the enhanced subsidies. On the flip side, congressional action would most likely be required to end or cut Medicaid expansion.

Would the multiple U.S. senators and House members in the red states that have expanded Medicaid vote to end a program that is providing health care to thousands of their constituents?

If Congress does not continue Biden’s enhanced subsidies, the rates for Mississippians on the exchange will increase on average about $500 per year, according to a study by KFF, a national health advocacy nonprofit. If that occurs, it is likely that many of the 280,000 Mississippians on the exchange will drop their coverage.

The result will be that Mississippi’s rate of uninsured — already one of the highest in the nation – will rise further, putting additional pressure on hospitals and other providers who will be treating patients who have no ability to pay.

In the meantime, the Mississippi Today counter that tracks the amount of money Mississippi is losing by not expanding Medicaid keeps ticking up.

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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Mississippi Today

On this day in 1911

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mississippitoday.org – Jerry Mitchell – 2024-12-21 07:00:00

Dec. 21, 1911

A colorized photograph of Josh Gibson, who was playing with the Homestead Grays Credit: Wikipedia

Josh Gibson, the Negro League’s “Home Run King,” was born in Buena Vista, Georgia. 

When the family’s farm suffered, they moved to Pittsburgh, and Gibson tried baseball at age 16. He eventually played for a semi-pro team in Pittsburgh and became known for his towering home runs. 

He was watching the Homestead Grays play on July 25, 1930, when the catcher injured his hand. Team members called for Gibson, sitting in the stands, to join them. He was such a talented catcher that base runners were more reluctant to steal. He hit the baseball so hard and so far (580 feet once at Yankee Stadium) that he became the second-highest paid player in the Negro Leagues behind Satchel Paige, with both of them entering the National Baseball Hame of Fame. 

The Hall estimated that Gibson hit nearly 800 homers in his 17-year career and had a lifetime batting average of .359. Gibson was portrayed in the 1996 TV movie, “Soul of the Game,” by Mykelti Williamson. Blair Underwood played Jackie Robinson, Delroy Lindo portrayed Satchel Paige, and Harvey Williams played “Cat” Mays, the father of the legendary Willie Mays. 

Gibson has now been honored with a statue outside the Washington Nationals’ ballpark.

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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