The Miami Herald reported the criminal charges of bribery against Bertha Blanco, a Florida health care administrator in exchange for helping a nursing home owner accused of orchestrating a $1 billion Medicare and Medicaid fraud scheme keep his license.  The wide-ranging investigation that federal authorities are calling the nation’s biggest health fraud case.

Blanco made about $31,300 a year overseeing inspections at nursing facilities owned by Philip Esformes, a wealthy businessman who owns dozens of Miami-Dade nursing facilities as well as homes in Miami, Los Angeles and Chicago.

A criminal complaint filed against Blanco accused her of taking tens of thousands of dollars in cash in exchange for tipping Esformes off about violations so he could address them before state inspections.  Blanco’s aid allowed Esformes to keep his license active and continue billing the federal government for questionable patient services.

Federal authorities say Blanco took the bribes and provided patient and inspection records to intermediaries, who delivered the information to Esformes.  Two of those intermediaries, brothers Gabriel and Guillermo Delgado, have made plea deals and are expected to testify against Esformes. The brothers helped investigators get to Esformes by videotaping a cash transaction that prosecutors said was meant to go for bribes.

Esformes is accused of using his 20 nursing facilities to file false Medicare and Medicaid claims for services that were not necessary for 14,000 patients.

Prosecutors said his health care network and other co-conspirators billed $1 billion for fraudulent services between 2009 and 2016.

CNN Money reported the great news for Ohio residents.  Health insurers in Ohio have agreed to sell Obamacare policies in 19 of the 20 counties that had no options for 2018, the state Department of Insurance said.  Roughly 11,000 Ohio residents in these counties currently purchase coverage on the exchange.

“The exchange markets are proving to be more resilient than many would have expected,” said Cynthia Cox, an associate director at the Kaiser Family Foundation. “Premium subsidies protect consumers from paying higher prices and may also make it possible for insurers to stay in counties that are otherwise unattractive.”

Trump is threatening to end insurance subsidies for low income people which will destabilize the market and prompt insurers to exit.  Hopefully, Trump will not intentionally sabotage the market.

Insurers have until late September to commit to participating on the exchanges for next year. That’s when they sign contracts with the federal government.

The Advocate reported the prison sentence for a mother-son team that defrauded Medicare for bogus psychological services for nursing home patients in Louisiana and three other states.  Prosecutors say Medicare paid out more than $13 million under the swindle.  A jury convicted psychologist Rodney Hesson and his mother, Gertrude Parker, each on charges of conspiracy to commit health care fraud and conspiracy to make false statements.

Hesson was sentenced to 15 years in prison and must pay back $13.8 million, and Parker to seven years and restitution of $7.3 million.  Hesson and Parker ran the fraud scheme through two companies: Nursing Home Psychological Services and Psychological Care Services.

The firms contracted with nursing homes in Louisiana, Alabama, Florida and Mississippi. Prosecutors argued at trial that the firms billed taxpayers thousands of times for psychological testing that the patients didn’t need and often never received.

Court records show that two other defendants in the case pleaded guilty last fall.

John Teal, a clinical psychologist, pleaded guilty to a conspiracy charge and was sentenced to two years in prison. Teal admitted to administering tests to nursing home patients who were “either non-responsive or were otherwise unable to meaningfully participate.”

Beverly Stubblefield pleaded guilty to a health fraud conspiracy count and received a 30-year sentence. She admitted she supervised five clinical psychologists and filed false documents.

The Des Moines Register had an editorial about the lack of federal oversight for nursing homes.  “The nation’s worst nursing homes have never received enough oversight, and the problem is getting worse.”

In 1998, federal regulators attempted to crack down on homes that had an established pattern of injuring and, in some cases, killing elderly residents, by creating a list of “special-focus facilities.” Nursing homes that wound up on the list were subjected to increased inspections and penalties.

However, fundamental problems with the way CMS implemented the program arose including refusing to share the list with the media or the public. CMS eventually began publishing the list each time it was updated, but only after The Des Moines Register reported on the secrecy and then-Sens. Tom Harkin and Hillary Clinton sponsored legislation to force disclosure.

The designation, as reported by Kaiser Health News in collaboration with the New York Times, have more serious problems with the way the list is compiled. The number of nursing homes that are designated special-focus facilities at any given time has dropped by nearly half in the past five years — and that’s not because care is improving. Rather, it’s because of federal budget cuts; the program’s $2.6 million budget allows only 88 nursing homes to receive the designation, even though regulators identified 435 as warranting the extra level of oversight.

“Kaiser’s research also shows that many special-focus facilities never clean up their act. More than a third of the nursing facilities that successfully graduated from the list before 2014, theoretically because they improved their care, still hold the lowest possible Medicare rating for health and safety: one star on a five-star scale. And of the 528 existing nursing homes that graduated from the list before 2014, slightly more than half subsequently harmed patients or put patients in serious jeopardy.”

“Taxpayers fund Medicaid and Medicare, which means they’re the ones providing the money that keeps these repeat offenders in business. When homes continue to provide poor care or rack up unpaid fines, CMS needs to act quickly in permanently shutting off the flow of taxpayer money.”

Nursing home administrators from around New Hampshire met with U.S. Sen. Jeanne Shaheen, D-N.H., about the impact on New Hampshire’s elderly if Congress passes TrumpCare.  The providers said they will suffer by passage of “Trumpcare.”

Brendan Williams, president and CEO of the New Hampshire Health Care Association, estimated each of the Granite State’s 76 nursing centers would lose $1.01 million under the proposal. He called the bill “absolutely inhumane.”  “It’s as dark a time for long-term care as I have ever seen it,” he said. “This would be a wrecking ball for New Hampshire’s fragile long-term care system.”

The administrators predicted passage would result in nursing home closures and facilities refusing to take Medicaid patients. Thomas Blonski, Catholic Charities’ CEO and president, said  “I can think of no better way to characterize the incredible extreme that this Medicaid funding crisis has reached than to that, in effect, we’re now providing charity to the state itself,” Blonski said.

NPR had a great explanation of Medicaid enrollment and expenditures.  The article explains that Medicaid is for the old, poor, and disabled, and the cost is reasonable.

Medicaid costs less than 10 percent of the federal budget.  Federal spending on Medicaid in 2015 was about $350 billion, almost one-tenth of the $3.7 trillion federal budget. That money is supplemented by the states, so total spending on Medicaid services was $545 billion that year. Those numbers have been increasing as health costs rise and the number of people who are eligible for the program expands.  By contrast, we spend over 50 percent on defense spending.

Medicaid pays for most nursing home care.  Medicaid pays the costs for about 62 percent of seniors who are living in nursing homes. Inpatient nursing care is some of the priciest health care out there, so even though seniors accounted for only 9 percent of Medicaid beneficiaries in 2014, they used 21 percent of Medicaid dollars, according to the Kaiser Family Foundation.

One third of Medicaid’s budget pays for disabled people.  Medicaid spends almost $200 billion a year caring for people with physical and intellectual disabilities. even though, according to the Center for Budget and Policy Priorities, only about 13 percent of those enrolled in Medicaid are disabled.

Medicaid pays for over half of all births.  Medicaid was established in 1965 as a program to help poor single parents on welfare, along with their children. Two decades after that, the federal government required states to cover poor women who were pregnant for the first time. And in the early 1990s, Congress expanded coverage for pregnant women further to ensure that all pregnant women and mothers of children under age 6 with incomes up to 133 percent of poverty — or $21,599 for a family of two — are covered. According to the Kaiser Family Foundation, about half of all births are now paid for by Medicaid, ranging from 72 percent in New Mexico in 2015 to 27 percent in New Hampshire.


WJHL reported that Tennessee took a look at a Medicaid cost report for the Erwin Health Care Center because a recent audit raised serious questions about the nursing home’s handling of funds back in 2012.  According to the report, 27 nursing home residents on Medicaid were “inappropriately” charged to their trust fund accounts for diapers — a Medicaid-covered item.  According to the “Medicaid Bulletin, “diaper’s cloth and/or disposable, is a nursing facility responsibility and considered a covered service.”  The publication also says, “For covered items, the nursing facility may charge no more than the difference between the cost of an item and/or service it provides and one specifically requested by the named resident.”

The state auditor says “as of May 23, 2017, management has provided canceled checks as evidence that $560.16 has been refunded to residents or their authorized representatives. The remaining $2,108.72 has yet to clear the bank.”

In addition, the audit pointed out the nursing home improperly managed credit balances and failed to deposit residents’ funds into an interest-bearing account.

In December, Maryland Attorney General Brian Frosh sued Neiswanger Management Services.  The lawsuit contends the firm wrongfully evicted patients without their consent once their Medicare coverage ran out, and without the planning the state requires for placing them in a safe, secure environment.  Frosh accused the company of evicting hundreds of vulnerable residents, in some cases dumping them in homeless shelters or unlicensed facilities, to maximize payments from public health plans.

Federal and state officials have terminated NMS Healthcare of Hagerstown from being authorized to serve Medicare and Medicaid consumers, according to the Maryland Department of Health and Mental Hygiene.

The U.S. Centers for Medicare & Medicaid Services informed the facility in a May 19 letter that it would be dropped from the Medicare program because it was not in substantial compliance with federal regulations.


The long-awaited nonpartisian Congressional Budget Office “score” of the House-passed version of Trumpcare states that 23 million Americans would lose health insurance coverage over the next ten years, as compared to current law.  CBO also found that after increasing premiums initially, Trumpcare would “eventually” reduce average premiums for policies offering far fewer benefits.

For older, poorer and sicker people, however, the picture is much darker.  CBO estimates premiums for some elderly low-income people could go up by 800 per cent.

A day after the White House released a $4 trillion budget full of draconian cuts aimed particularly at poor people is not the best time to discover that its health care bill will deny health insurance to 23 million Americans. As CBO notes, AHCA would reduce federal revenues by $992 billion — in no small part by cutting taxes on wealthy people.