Posts Tagged ‘Charles Duarte’

Nevada Among States With Lowest Spending On Health Care And Least Number Of Insured

By Sean Whaley | 2:35 pm December 20th, 2011

CARSON CITY – Nevada ranks 46th among states on spending on health care per capita, according to a report released this month by the Centers for Medicaid & Medicare Services.

Nevada spends $5,735 per person on total personal health care as of 2009, the report says. The national average is $6,815. The highest per capita spending was found in Massachusetts at $9,278.

Larry Matheis, executive director of the Nevada State Medical Association, said Nevada’s low spending on health care is a reflection of the large number of residents who don’t have health insurance.

U.S. Census data released in October shows that Nevada is the third most uninsured state per capita in the U.S as of 2009.

“On first blush it’s good news that we’re not on the high end of spending per person,” Matheis said. “But a more balanced look at the data says we have a lot of warning signs in this pool of data. It renders a number that looks like we’ve got costs under control. It actually just means we have a big access problem.”

The report found that eight of the ten top states for total health care spending per capita, including Massachusetts, Connecticut, and New York, are also ranked in the top third in the nation for annual personal income per capita.

Photo by James Gathany, Centers for Disease Control and Prevention.

“Income appears to have an important and positive relationship with health spending,” the report said.

Matheis said the study provides much-needed information as the country moves forward with full implementation of the national health care law.

“They need much better baseline information about how much they are spending and on what with every population and in every part of the country, because a big part of the reform proposals are aimed at trying to, if not reduce costs, reduce the things that lead to higher costs,” he said.

Report also looks at Medicare and Medicaid spending

The report shows that Nevada is in the middle of the pack in terms of Medicare spending per enrollee at $9,692, and ranks toward the bottom of the states on Medicaid spending per enrollee at $6,003. The national averages are $10,365 and $6,826, respectively.

But in terms of the percentage of health care dollars spent on Medicaid, Nevada is lowest among all states at only 8.6 percent. Nevada is the only state where spending is in the single-digits. The highest is New York, where 29.2 percent of all personal health care spending is via Medicaid.

Medicaid is the health care program for low income seniors, disabled and families, the cost of which is shared by states and the federal government.

Charles Duarte, administrator of the state Division of Health Care Financing and Policy, which oversees the Medicaid program, said Nevada’s spending is low because of the policy decision to restrict eligibility. The program also doesn’t offer many optional services that can increase costs.

“We’ve made decisions as a state that we’re not going to expand the program from an eligibility perspective,” he said. “And so in other states Medicaid makes up 14, 15, 16 percent of coverage for people in the state. In some states it is as high as 30 percent.

“We don’t cover as many people in our public programs, but our employers are kind of right in the middle there, slightly above the national average,” Duarte said. “And what the means is the uninsured group are those that could be covered by Medicaid if our rules allowed it.”

Federal health care law expected to affect Nevada Medicaid spending

This situation is expected to change as the Medicaid program expands beginning in 2014 as part of the implementation of the federal health care law, he said. As many as 100,000 new residents could be eligible for Medicaid. There are residents eligible for Medicaid now who are not participating in the program who will have to be covered as well, Duarte said.

The cost of the newly eligible residents will be covered almost entirely by the federal government, but the state will share in the cost of those who are eligible now but who have not signed up for the program, he said.

This Medicaid expansion is one reason Nevada joined with many other states in challenging the constitutionality of the health care law. The U.S. Supreme Court has agreed to review the law. Former Gov. Jim Gibbons in 2010 estimated the Medicaid mandate will cost Nevada $613 million over six years beginning in 2014. Gibbons initiated Nevada’s participation in the challenge to the law which is being continued by Gov. Brian Sandoval.

Matheis said there is a strong feeling in the Nevada medical community that the state is under-spending on this population, which will have to change with the implementation of the health care law.

“Nevada is going to go from where we are now, which is a very low spending per Medicaid patient; we’re going to jump a huge amount because there are going to be so many people that will be identified for the new Medicaid expansion that is coming under the Affordable Care Act,” he said.

This rapid expansion will create budget challenges for state lawmakers, Matheis said.

Policy-makers need to seriously consider the data and build it into the state’s planning efforts, he said.

“At some point we do have to invest in a health care system that we want,” Matheis said. “Right now we’re doing that in Nevada minimally and that’s what this report really shows.”

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Audio clips:

Larry Matheis, executive director of the Nevada State Medical Association, says the report provides much needed baseline information:

122011Matheis1 :24 to higher costs.”

Matheis says Nevada will see a big jump in Medicaid spending because of the new health care law:

122011Matheis2 :25 Affordable Care Act.”

Matheis says the news looks good at first, but it suggests there are concerns:

122011Matheis3 :19 pool of data.”

Charles Duarte, administrator of the state Division of Health Care Financing and Policy, says Nevada’s Medicaid spending is low because eligibility is restricted:

122011Duarte1 :15 high as 30 percent.”

Duarte says the uninsured group in Nevada are those who could be covered by Medicaid if eligibility was expanded:

122011Duarte2 :18 rules allowed it.”

 

Medicaid Information System Goes Live By Deadline, No Major Issues Expected

By Sean Whaley | 3:32 pm December 5th, 2011

CARSON CITY – A state official said today the firm hired in January to take over the operation of the Medicaid billing and information systems has completed its work by today’s deadline.

HP Enterprise Services was given a four-month extension to complete the transfer and start-up of the system after it failed to make an Aug. 1 deadline.

Today, Charles Duarte, administrator of the state Division of Health Care Financing and Policy, which oversees the Medicaid program, said the transfer was completed by the new deadline.

“We’re on schedule,” he said.

The firm started up a new piece of the system, the pharmacy claims system, on Friday, he said.

Photo courtesy of User.Oaktree_b via Wikimedia Commons.

“There were a few issues over the weekend but nothing major,” Duarte said.

Some of the national pharmacy chains had to send the software to their local stores, he said.

The main piece of the system, the Medicaid Management Information System, went live Sunday at 11:30 p.m., Duarte said.

“All our call centers are operating,” he said. “So everything is moving along.

“A big test will be when we actually adjudicate those claims tonight, both electronic and paper claims, to see what kind of performance we get out of the system tomorrow,” Duarte said. “But we’re very optimistic that things will process well this evening.”

The testing of the system in parallel with the old system worked out very well, he said. There will probably be a few glitches, but nothing major, Duarte said.

The Nevada News Bureau first reported in October that the contractor, hired in January to operate the system for $177 million over five years, had missed its Aug. 1 deadline.

Duarte said today that the Nevada Department of Health and Human Services will enter into discussions with HP Enterprise Services regarding the missed deadline now that the transfer has been completed. The state does have the ability to seek damages for a failure of the company to deliver on the terms of the contract, he said in October.

“Because of the need to focus on getting the system operational, get it standing up, we moved off that and are going to reengage them in that discussion again,” Duarte said. “So once all systems are green and everything is working well it’s going to be time to sit down and talk about the contract.”

The HP contract was approved by the Board of Examiners, including Gov. Brian Sandoval, in January, but not without controversy. The second lowest bidder, ACS, raised numerous concerns about the negotiations that resulted in HP winning the contract, including $30 million in additional value that brought the cost of the HP bid close to that of ACS. The company did not formally challenge the award, however, because of the costs involved.

The Medicaid information system is critically important to Nevada and the U.S. Department of Health and Human Services, which share in the costs of delivering medical services to the approximately 300,000 low-income Nevada recipients, typically families, seniors and the disabled.

Once the system is certified by the federal Centers for Medicare & Medicaid Services next year, the state expects to see enhanced federal reimbursements for the Medicaid program, he said.

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Audio clips:

Charles Duarte, administrator of the state Division of Health Care Financing and Policy, which oversees the Medicaid program, says the main part of the system went live Sunday at 11:30 p.m.:

120511Duarte1 :24 is moving along.”

Duarte says a big test will come tomorrow after the claims are processed this evening:

120511Duarte2 :17 well this evening.”

Duarte says the state will discuss the contract and delay with HP now that the system is functional:

120511Duarte3 :15 about the contract.”

 

New Medicaid Contractor Misses Deadline After Controversial Bid Award

By Sean Whaley | 12:54 pm October 20th, 2011

CARSON CITY – A firm hired in January to take over operation of the state’s Medicaid billing and information systems has failed to complete the first key step in the process by an August deadline and has been given an extension to Dec. 5.

The Medicaid contract with HP Enterprise Services is one of the biggest for the state at a cost of $177 million over five-plus years, and proved controversial when it was approved by state officials in January.

HP had originally committed to transferring the existing Medicaid Management Information System now being operated by Magellan Medicaid Administration by Aug. 1, a five-month process that began March 1.

But Charles Duarte, administrator of the state Division of Health Care Financing and Policy, which oversees the Medicaid program, said this week the work was not completed by the deadline. The Department of Health and Human Services agreed to an extension to Dec. 5 to complete the transfer, he said.

The issue was HP finding the number of qualified staff it needed to complete the transfer on time, Duarte said.

The company is on track to complete the transfer by the new deadline, an assessment shared by a separate independent contractor called Public Knowledge hired by the state to oversee the work, he said.

“So far what we’ve seen with HP is they have been very willing to live up to their commitments and we’re going to hold them to that,” Duarte said.

An HP executive involved in the transfer said today the new deadline will be met.

“We’re definitely firing on all cylinders to make that date,” said Stu Bailey, general manager for state and local government health care in the Western U.S. for the company. “We meet with the state on a regular basis to ensure that. The IV&V (independent validation and verification) has been heavily involved to validate that what we’re saying and what we’re doing is on track, so we’re feeling comfortable that that date will be met.”

Bailey said two issues, one involving the scope of the project not being precisely as it was described in the request for proposal, and the other being staffing issues, led to the delay. The company is transferring its California Medicaid contract to a competitor and the process has taken longer than expected, making staff unavailable for the Nevada transfer, he said.

The HP contract was approved by the Board of Examiners, including Gov. Brian Sandoval, in January, but not without controversy. The second lowest bidder, ACS, raised numerous concerns about the negotiations that resulted in HP winning the contract, including $30 million in additional value that brought the cost of the HP bid close to that of ACS.

Because of the cost involved in filing a formal protest, including a $245,000 non-refundable charge to post a bond, ACS elected not to challenge the award, however.

ACS elected not to comment for this story.

Duarte said the delay in completing the transfer is resulting in some missed savings to the state, but the amount of money lost so far has not yet been quantified. State officials do expect the company to make up those lost savings once the transfer is complete, he said.

“There are other ways of achieving those savings through the contract term and we’re going to leave that open for discussion after the transfer,” Duarte said. “All of our focus right now is making sure that that goes off smoothly so there is no interruption in provider payments and authorization of services for Medicaid recipients.

“But I will be intently working with them after the takeover to make sure that we can achieve those savings that we said we were going to achieve – and that they said they would,” he said.

The Medicaid information system is critically important to Nevada and the U.S. Department of Health and Human Services, which share in the costs of delivering medical services to the approximately 300,000 low-income Nevada recipients, typically families, seniors and the disabled.

Source: U.S. Government.

Nevada health care providers, including doctors and dentists, suffered major financial difficulties in 2003 when the state transitioned to a new Medicaid information system operated by First Health Services Corp. that encountered numerous problems when it first started up.

Bailey said he has been made well aware of the concerns, not only by Duarte and his staff, but by Nevada lawmakers and health care providers as well.

The company has been meeting with state officials and the current contractor on a weekly basis for the past six months to ensure a smooth transition, he said.

Duarte said the HP contract is not for a new system, but what he calls a “lift and drop” where the existing system is transferred to the new contractor.

The transfer process is now in the stages where both systems are being tested in parallel prior to finalizing the transfer, he said. The timely transfer of the system is important because some of the Magellan staff is going to work for HP, and so the company won’t be able to continue to provide the services required indefinitely, Duarte said.

“There is going to be a point in time in which Magellan can’t continue full operations, and so again, that is another driving reason why we want to get this done Dec. 5,” he said.

HP Enterprise Services will serve as the fiscal agent for the state’s Medicaid program when the transfer is complete, managing the state’s Medicaid system, including the processing of payments to medical providers, for the life of the contract.

Duarte said the state does have the ability to seek damages for a failure of the company to deliver on the terms of the contract, but that the decision at this point was not to “lawyer up” but instead to get the work done.

The federal Department of Health and Human Services is also involved in ensuring HP and the state get this work done, he said. When certified, Nevada will get enhanced federal funding, he said.

The Medicaid program is one of the costliest in the state budget, accounting for $1.6 billion this year, with $500 million of that coming from the state general fund. Federal support and other sources make up the rest of the budget.

HP Enterprise Services is the largest provider of Medicaid information system services in the country, operating in 21 of 38 states that have outsourced their programs. It processes about 1 billion provider claims each year.

Bailey said the company is successful because it works to ensure client satisfaction.

“I’ll tell you it’s not enough for us to have the business,” he said. “Beyond that we need to have clients that are happy. Client satisfaction is big on our radar screen.”

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Audio clips:

Nevada state Medicaid Administrator Charles Duarte says the focus now is completing the transfer on time and without disruption:

101911Duarte1 :22 for Medicaid recipients.”

Duarte says he will be working with HP to ensure projected savings are achieved:

101911Duarte2 :11 said they would.”

Duarte says HP so far has been willing to live up to its commitments:

101911Duarte3 :08 them to that.”

Duarte says the current contractor won’t be able to continue to provide services indefinitely:

101911Duarte4 :11 done Dec. 5.”

HP Executive Stu Bailey says the company is confident it will make the Dec. 5 deadline:

102011Bailey1 :22 will be met.”

Bailey says client satisfaction has been important to the company’s success:

102011Bailey2 :33 doing for them.”

 

State Agency Focuses On Waste And Abuse As Well As Fraud In Medicaid Program

By Sean Whaley | 2:00 am September 28th, 2011

CARSON CITY – It isn’t just fraud, but waste and abuse of Medicaid funds that state officials are taking aim at as the cost of the health insurance program for children, seniors and the disabled continues to climb.

Charles Duarte, administrator of the state Division of Health Care Financing and Policy, which oversees the Medicaid program, said efforts to identify fraud, waste and abuse have been stepped up since 2005 when only two staff in his office were dedicated to these important tasks.

Charles Duarte, administrator of the state Division of Health Care Financing and Policy.

Now there are nine staff devoted to such reviews, and auditors can also be brought in when there is reason to believe an in-depth analysis is needed, he said.

Called the Surveillance and Utilization Review Section (SURS), the team is another line of defense against abuses of the Medicaid program along with the Attorney General’s Medicaid Fraud Control Unit and the investigations and recovery activities within the state Division of Welfare and Supportive Services, programs highlighted in a Nevada News Bureau story published Friday.

“If you are looking at it as a pyramid it is really waste that is the big component, and then abuse and then fraud,” Duarte said.

His staff closed 290 cases in Fiscal Year 2008, a number that reached 817 in Fiscal Year 2011.

“So the numbers of cases we have currently being reviewed and investigated has grown dramatically over the last five years,” he said. “And as a result, we have been able to recover, on average, about $2 million to $3 million each year with regard to improper payments.”

Medicaid is big business in Nevada and nationally.

Nevada’s Medicaid budget for this 2012 fiscal year totals $1.6 billion, with just over $500 million coming from the state general fund. The federal government is paying 55 percent of the cost of the Nevada Medicaid program this year. Other local funds are also used to support the program.

The budget continues to grow as more Nevadans become eligible for services. In August 2009 there were just over 230,000 recipients. Two years later in August 2011 there were just over 300,000 recipients, an increase of 30 percent.

The federal government focused on Medicaid fraud in 2006 with a new law creating the Medicaid Integrity Program, identified as the “first comprehensive federal strategy” to prevent and reduce fraud, waste and abuse in the $300 billion per year program.

Concerns over Medicaid fraud have caught the attention of state lawmakers as well.

Assemblyman Cresent Hardy, R-Mesquite, proposed legislation in the 2011 legislative session to study the effectiveness of current Medicaid fraud prevention efforts and identify ways to improve efforts to combat the problem.

Assemblyman Cresent Hardy, R-Mesquite.

A contractor, Hardy testified that he identified two Medicaid fraud cases in two years in his own business. Assembly Bill 286, which had bipartisan support, did not win final approval, however.

“That’s what I wanted to look at and see how prevalent it was, and get the businesses involved to see if we could educate them in how to maybe identify this,” he said. “Because everybody that takes it illegally is taking it out of the mouths or the hands of those who really need it.”

Hardy said Duarte and other state officials need the tools to do their jobs.

“I really do believe we should be doing more to fight this thing, both at the state level and at the federal level,” he said.

Even without the review, state officials say Medicaid fraud is a priority.

Duarte’s staff spends much of its time analyzing data looking for “statistical outliers” or deviations in the normal parameters of billing activity, to identify potential areas of concern.

“And so we do a lot of the work up front for other branches of state government that may be involved either in prosecution or recipient-level fraud,” Duarte said. “So we’re the front line with regard to those types of reviews.”

There is also a deterrence effect from the reviews, he said.

“The word gets around,” Duarte said.

Some cases are resolved with education of a provider or group of providers, he said. But repeat offenders could be audited to recoup excess payments. If there is criminal intent, then the case is referred for potential prosecution, Duarte said.

There is also prospective review, such as checking the status of a provider seeking to do business with the Medicaid program in Nevada, he said. There have been cases where a business has been shut down for bad acts, but the same individuals establish a new company in an effort to continue to provide Medicaid services, Duarte said.

Fraud cases can involve a variety of activities, including providers who bill for services that are not even provided, he said.

In 2010 for example, the agency cut off all payments to Ujima Youth Services, which operated group homes at several locations in Reno, after an audit showed the company’s records did not support the amount that was billed to Medicaid. The Secretary of State’s Office shows there is no longer any active business entity by that name in Nevada.

“You want folks to have an appreciation that we appreciate their tax dollars and how (they are) being used,” he said. “It’s really an issue of stewardship on our part and on the part of the federal government.”

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Audio clips:

Charles Duarte, administrator of the state Division of Health Care Financing and Policy, says his office looks at waste, abuse and fraud:

092711Duarte1 :23 and then fraud.”

Duarte says his staff does a lot of the upfront work looking into Medicaid fraud:

092711Duarte2 :10 recipient level fraud.”

Duarte says his staff have been able to recover between $2 million and $3 million in improper payments:

092711Duarte3 :20 to improper payments.”

Assemblyman Cresent Hardy says more needs to be done to fight Medicaid fraud:

092711Hardy1 :31 the suppliers themselves.”

Hardy says those who illegally receive Medicaid take it from those who really need it:

092711Hardy2 :15 really need it.”