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(From the Pennsylvania Attorney General’s office)

Attorney General Josh Shapiro Announces Grand Jury Recommendations for the Pennsylvania Medicaid Program

CONTACT: Joe Grace, 717-574-9095,

HARRISBURG — Attorney General Josh Shapiro today announced recommendations from a statewide Grand Jury investigation into the Pennsylvania Medical Assistance (MA) Program. The legislative actions recommended by the Grand Jury aim to assist the Pennsylvania Department of Human Services in identifying and preventing fraud from occurring in the program and provide law enforcement, particularly the Pennsylvania Office of Attorney General’s Medicaid Fraud Control Section, with the tools it needs to effectively investigate fraud within the program.

The Pennsylvania Medical Assistance—or Medicaid—program is implemented by the Department of Human Services and provides care to more than 2.7 million low-income Pennsylvanians. The Office of Attorney General’s Medicaid Fraud Control Section is dedicated to prosecuting anyone who defrauds the MA Program through unlawful billing or failing to provide services to those whom the program serves.

In the 2017 and 2018 calendar years, the Medicaid Fraud Control Section made a total of 292 arrests, achieved 173 convictions, and recovered more than $34 million for the commonwealth, making it the third highest ranking Medicaid fraud control unit in the country. Last month, the Section was nominated and selected for the U.S. Inspector General’s Award for Excellence in Fighting Fraud, Waste, and Abuse.

“Medicaid provides essential care to some of Pennsylvania’s most vulnerable citizens, including low-income individuals, children with serious health conditions, and individuals suffering from substance use disorder,” said Attorney General Josh Shapiro. “When bad actors take advantage of the system, they deny these people the care they deserve, take advantage of hard-working care providers, and scam Pennsylvanians out of their hard-earned tax dollars.”

This investigation stemmed from two independent Medicaid Fraud investigations that prompted the Grand Jury to conduct an investigation into how to identify and prevent fraud and ensure delivery of satisfactory care within the MA Program.

The Grand Jury heard testimony from state regulators, law enforcement officials, managed care organizations (MCOs), and health care providers about the MA program. They identified the following three systemic issues within the MA program that permit the exploitation of care-dependent Pennsylvanians for financial gain and impact the quality of care provided:

  1. The MA system does not currently require the individual providing services to be identified on the claim submitted for payment.
  2. MA claims submitted for payment do not require specific date and time information before payment is made.
  3. The individuals providing these services lack the knowledge and training to provide quality care and to properly bill for those services.

The Grand Jury heard evidence from six cases that illustrate these deficiencies in the system. In one case, an individual who was simultaneously working for three behavioral health agencies and as a substitute special education teacher would submit timesheets claiming she was providing services which overlapped with each other and/or her work as a teacher. The Grand Jury concluded that her fraud would have been caught sooner if there had been a mandate that the claims identify her as the individual providing the services and include specific dates and times of the services.
In a second case, a mother of a daughter with autism was directing her daughter’s caregivers to provide unauthorized services such as painting the house, feeding the dog, and running household errands. She was also instructing the workers to report their services incorrectly and falsely reporting that her husband and son provided services. The Grand Jury concluded that if the program had a standardized training module, the workers would have been able to identify that they were being required to document their services improperly and that the tasks assigned to them were not authorized. They would have also been more informed about how to report these violations.

The Grand Jury provided the three following recommendations to address these deficiencies. The Grand Jury asserted its belief that these recommendations will assist DHS in carrying out its mission and will provide the MFCS with the tools it needs to effectively combat fraud, resulting in increased criminal convictions and recoveries:

  1. State Provider Identifier (SPI): The legislature should enact a statute mandating that any individual seeking to provide services paid for, in whole or in part, with MA funds who does not have a National Provider Identifier (NPI) be required to register with the Commonwealth of Pennsylvania and obtain a SPI prior to the performance of said services. The legislation should mandate that every claim for MA services identify the actual individual providing the services by requiring that the providing individual’s NPI or SPI be placed on every claim.
  2. Date and Time Specificity: The legislature should enact a statute mandating that every claim for MA services document every date that a service was provided as well as the start and end times for each date of service.
  3. Standardized Training: The legislature should require that DHS establish and mandate standardized training for all persons providing services utilizing SPI. The standardized training should be specific to the type of services being provided and focus on the required level of care the recipient is to receive and what services are appropriately billable under that program. The training should also provide information on how to contact Protective Services and where to report fraud within the MA program.  The standardized training for each specific type of service must be completed prior to providing services.

“Working with our partners in Governor Wolf’s Department of Human Services, we’re dedicated to doing everything in our power to ensure that the Medical Assistance Program runs as effectively as possible and minimize its vulnerability to fraud,” said Attorney General Shapiro. “I am grateful for the work of the Grand Jury to develop comprehensive, manageable recommendations for how to identify and prevent fraud in the program. These recommendations will make it easier for law enforcement to protect Pennsylvanians and for DHS to make sure people are getting the care they need.”

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The Pennsylvania Department of Labor & Industry’s (L&I) has reached out to RCPA in response to our letter last summer requesting an extension for the regulatory public comment period on the white collar overtime exemptions from Pennsylvania’s Minimum Wage Act. L&I has received numerous comments from stakeholders indicating that there is a lot of interest in the proposed rulemaking regarding the overtime exemptions.

As a result, L&I has contacted RCPA to determine if there is member interest in roundtable education and discussions on the white collar exemptions. L&I wants the opportunity to engage employers and affected organizations in a frank discussion on the application of these exemptions, and how the department can help employers and organizations comply with the exemptions’ requirements. Some of the public comments received indicated that there is some misinformation surrounding the required factors that would trigger any of the overtime exemptions. L&I stated that they would be open to any constructive suggestions that impacted individuals and groups may have in moving forward with modifications to the existing proposal.

L&I is in the process of setting up stakeholder outreach meetings in mid to late May and early June in five locations across the state:

  • Pittsburgh – Wednesday, May 15
  • Erie – Thursday, May 16
  • Harrisburg – Wednesday, May 22
  • Philadelphia region – Wednesday, May 29
  • Scranton region – Wednesday, June 5

While the above dates are tentative, they will be confirmed later this month. If your organization would like to attend one of these meetings, please send your request to Jack Phillips, RCPA’s Director of Government Affairs, by Thursday, April 25.

L&I has requested that participants come prepared with questions about the exemptions, as well as comments on how they believe exemptions may impact their operations. L&I has asked for no more than 15 participants at each session; this will allow them to hear from and engage with each individual and the organization they represent. Thank you in advance for your participation and cooperation. Please forward questions to RCPA Director of Government Affairs Jack Phillips.

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(Source: Buchanan, Ingersoll and Rooney, PC, Daily Health Care Daily Roundup, April 3, 2019)

Following House passage last week, the Senate passed, by voice vote, the Medicaid Services Investment and Accountability Act of 2019 (H.R. 1839), legislation that includes short-term extensions of several Medicaid programs such as the Money Follows the Person Program – which helps transition individuals with chronic conditions and disabilities from institutions back into their local communities to get care – and the Community Mental Health Services Demonstration Program, which allows community providers to expand access to treatment for mental and behavioral health. Specifically, the bill provides $20 million in additional grant funds for the Money Follows the Person Program and extend the Community Mental Health Services Demonstration Program through June 30, 2019, or for two years, whichever is longer. In addition, the bill:

  • Includes provisions of the Right Rebate Act, which allows the Secretary of Health and Human Services to require drug manufacturers to reclassify their drugs and impose civil monetary penalties when drugs are knowingly misclassified in the Medicaid Drug Rebate Program (MDRP);
  • Increases the number of days (from 90 to 100) that a state may delay payments in Medicaid to providers for medical services provided to a child with a medical support order; and
  • Extends states’ flexibility to disregard individuals’ spousal income and assets when determining eligibility for home and community-based services and supports through September 30, 2019.

Finally, the bill includes provisions of the Advancing Care for Exceptional (ACE) Kids Act that creates a state option to establish health homes for children with medically complex conditions, as well as provide two quarters of enhanced federal matching funds for states’ payments to health homes. The bill now heads to the President for his signature.

Questions, please contact Jack Phillips, Director of Government Affairs.

(From DHS Secretary Miller)

Effective March 25, Valerie Vicari is serving as Acting Deputy Secretary for the Office of Mental Health and Substance Abuse Services (OMHSAS). I would like to thank Lynn Kovich for her service to OMHSAS and Pennsylvania.

Valerie has been working in the ever-evolving human service field for over 25 years.  Her work has included experience in the children and youth service system and the behavioral health service system, both drug and alcohol services as well as mental health services.  Her various roles have included direct service, case management, county administration, and Commonwealth administration.  Valerie has been a leader within the behavioral health arena since the inception of the Medicaid Behavioral Health HealthChoices program in 2008.  She was part of the Office of Mental Health and Substance Abuse Services team that brought innovative behavioral health community programming to Pennsylvania.  Some examples of service development include telepsychiatry, Certified Peer Specialist (CPS) programs, Long Term Structured Rehabilitation programs (LTSR), and Assertive Community Treatment (ACT) teams.  As services evolved, telepsychiatry, CPS and ACT programming expanded to include individuals who have both behavioral health issues as well as forensic involvement.

Valerie’s most recent position has been the Chief Executive Officer at Torrance State Hospital since June 2016.  The oversight responsibilities include but are not limited to the civil psychiatric services, the Regional Forensic Psychiatric Center (RFPC) and the Sexual Responsibility Treatment Program (SRTP).  There are over 300 patients served at Torrance State Hospital on an ongoing basis.  In her leadership role at Torrance the hospital has become tobacco free, telepsychiatry has been developed within the forensic unit and numerous recovery focused initiatives have commenced.

People are complex, and their overall health is shaped by a variety of factors, many of which may not be visible or evident based on a conversation. We must equally focus on behavioral health and physical health and their interconnected nature in order to truly help the people we serve. Our mental and physical health do not exist in isolation, and both are influenced by the external circumstances in a person’s life.

You may know that we are working to improve care for Pennsylvanians by encouraging a whole-person focus that includes social determinants of health as well as physical and behavioral health needs. We want to encourage our physical and behavioral health providers and social service providers to work together to ensure that people do not slip through the cracks so we’re able to make a meaningful difference in their lives. Your work can help us move towards better long-term health outcomes for Pennsylvanians who use our services, and I am excited to partner with each of you to meet this goal.

On behalf of Governor Wolf, we are grateful to your commitment to the commonwealth and people affected by mental health and substance use disorders. Thank you for the work you do to elevate these issues and help people live better lives every day.

Thank you,

Secretary Teresa Miller

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(From DHS news room)

Wolf Administration: Trump-Proposed Cuts to Federal Health Programs Jeopardize Access to Life-Saving Health Care

Harrisburg, PA – The Wolf Administration today spoke out against potential cuts contained in President Trump’s proposed federal budget, which would significantly change Medicare, Medicaid, and the Affordable Care Act. In total, these programs help more than 5.5 million older, working, and low-income Pennsylvanians access routine and life-saving health care.

Under President Trump’s proposed budget, Medicaid expansion, which currently covers nearly 700,000 Pennsylvanians, would be eliminated. Medicaid would also be converted from an entitlement program that provides coverage to all who are eligible to block grant allocated to states based on a per-person funding cap.

“Medicaid allows more than 2.8 million Pennsylvanians to access health care coverage that would otherwise be unaffordable or inaccessible. Changing the program to a block grant system and eliminating the Medicaid expansion would result in significant losses of coverage and more people being unable to access the care they need to stay healthy,” said Human Services Secretary Teresa Miller.

The federal budget also proposes a nationwide work requirement for able-bodied, working-age Medicaid recipients, requiring them to find work, train for work, or volunteer in order to maintain coverage. This requirement would be similar to what is in place for Temporary Assistance for Needy Families (TANF) recipients, a program the Wolf Administration is currently redesigning to address barriers to employment and encourage better long-term employment outcomes for TANF recipients.

“A work requirement doesn’t get a person a job — let alone a family sustaining job. It jeopardizes their access to health care and other essential needs, and without the investment needed to assist them to address the factors that can hold them back, they continue to be stuck in a cycle of poverty and poor health,” said Secretary Miller. “Governor Wolf is redesigning Pennsylvania’s employment and training programs to better address the barriers that prevent people from obtaining family-sustaining jobs. The federal government should follow this work rather than creating another barrier to good health.”

The President’s proposed budget also encourages implementing the ACA replacement proposed by Senators Bill Cassidy and Lindsey Graham, which would end protections against inflated pricing for older consumers, tax credits for plans purchased through the health insurance exchange, and essential health benefits, among others. The plan was previously called a step backwards by the Wolf Administration in 2017.

“Pennsylvania’s uninsured rate is at an all-time low of just 5.5 percent, down from more than double digits before the Affordable Care Act took effect. Governor Wolf and I continue to strive to ensure all Pennsylvanians have access to coverage that is both affordable and comprehensive. Unfortunately, this budget would move in the opposite direction,” Insurance Commissioner Jessica Altman said. “We need to build upon the progress we have made, and not look to policies like those contained in President Trump’s budget proposal that could jeopardize the coverage gains we have made and the health care programs millions of Pennsylvanians rely on.”

Commissioner Altman noted for 2019, the aggregate statewide premium for individual ACA plans fell by 2.3 percent, a new insurer entered the state, and consumers in 30 counties had more options than in 2018, all indicating Pennsylvania’s individual health insurance market is moving toward stabilization.

“Under the Older Americans Act, the Department of Aging is responsible for serving as a visible and effective advocate on behalf of older Pennsylvanians,” said Acting Secretary of Aging Robert Torres. “President Trump’s proposed budget is the antithesis of what our seniors need and deserve.”

The budget proposes a 20% decrease in funding to the National Family Caregiver Support Program, a 26% percent decrease in funding to the State Health Insurance Assistance Program, and the elimination of funding for the Senior Community Services Employment Program and Elder Falls Prevention.

The administration called on President Trump and Congress to work together on federal health plans that break down barriers to work without jeopardizing vulnerable Pennsylvanians’ access to health care.

“Although this proposal is unlikely to pass Congress in this form, the spirit of this proposed budget still presents a cruel agenda that would jeopardize access to quality health care, making it more difficult for millions of Pennsylvanians,” said Secretary Miller. “Medicaid, Medicare, and the Affordable Care Act are lifelines, and the federal government must recognize the important role they play in many lives and strengthen these programs so they may continue to help people live healthy, productive lives for years to come.”

MEDIA CONTACT:   Ali Fogarty – 717.425.7606
Ron Ruman, PID – 717.787.3289
Drew Wilburne, Aging – 717.705.3702

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RCPA will be monitoring the federal budget in conjunction with our national associations and will inform members about any important updates. Further questions may be directed to Jack Phillips.

The Coalition to Preserve Behavioral HealthChoices, which includes RCPA, has signed onto a letter that will be sent out to members of the General Assembly stating “strong opposition to House Bill 335.” This bill calls for elimination of the Behavioral Health Carve-Out, known as Behavioral HealthChoices (BHC). BHC is the statewide program through which every county delivers mental health and drug & alcohol services to vulnerable Pennsylvanians enrolled in the Medical Assistance program, and their families. Please contact RCPA Director of Government Affairs Jack Phillips with any questions.

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Yesterday, after Governor Wolf delivered his 2019/20 budget address to the General Assembly, the Department of Health (DOH) and the Department of Human Services (DHS) held a budget briefing updating stakeholders on the status of 2018/19 initiatives and rolling out the Governor’s 2019/20 DOH/DHS budget initiatives. The Governor’s main initiatives for DOH and DHS for the upcoming fiscal year are as follows:

  • Increase the minimum wage;
  • Help low-income working parents support their families;
  • Strengthen high quality care for infants and toddlers;
  • Expand evidence-based home visiting;
  • Expand services for individuals with intellectual disabilities and autism on the waiting list;
  • Protect individuals in personal care homes and residential and day-treatment programs;
  • Support Pennsylvanians with disabilities;
  • Invest in mental health services; and
  • Combat the opioid epidemic.

For further information on the above initiatives, please see the DOH and DHS PowerPoint presentations. Questions, contact RCPA Director of Government Affairs Jack Phillips.