4th Circuit Affirms Withholding of WV Medicaid Funds

Today the United States Court of Appeals for the 4th Circuit affirmed a ruling by the district court in West Virginia which sustained a disallowance of federal funding by the Centers for Medicare & Medicaid Services (CMS) against the West Virginia Medicaid Program.

The 4th Circuit Decision in West Virginia Department of Health and Human Resources, Bureau for Medical Services vs. Kathleen Sebelius, et al. ruled that CMS acted within its authority when it withheld from the West Virginia Department of Health and Human Resources, Bureau of Medical Services, West Virginia'a Medicaid Program (DHHR) approximately $634,000 (which was reduced to approximately $446,000)in Medicaid funding, which represented it share of overpayment made to providers as a result of Dey, Inc., a pharmaceutical company, alleged fraud. CMS notified DHHR of the disallowance after Dey entered into an $850,000 settlement of claims brought by the West Virginia Attorney General on behalf of West Virginia under West Virginia's Consumer Credit and Protection Act.

The disallowance by CMS was calculated by multiplying the state's estimated damages allocable to Medicaid, approximately 67% by the settlement amount adn then multiplied this figure by West Virginia's FMAP rate of 78.14% to arrive at the $446,000 amount. The HHS Department of Appeals Board concluded that this allocation methodology was reasonable.

I have only done an initial review of the decision and won't go into the merits of the arguments at this time. Read the full decision for a more complete understanding of the decision and check out today's article in the Charleston Daily Mail.

WVDHHR Transfers OHFLAC Staff and Operations to OIG

According to the West Virginia Department of Health and Human Resources (DHHR), the West Virginia Office of Health Facility Licensure and Certification (OHFLAC) will be transferred to the West Virginia Office of Inspector General (OIG) effective February 1, 2010. OHFLAC oversees the state and federal licensure and certification process in West Virginia for hospitals, critical access hospitals, behavioral health facilities, home health agencies, hospice agencies, ESRD services, and other health care services.

All personnel and positions currently assigned to OHFLAC will be administratively transferred. DHHR has states that this action is to further enhance the integrity of the regulatory unit of the Department of Health and Human Resources.

West Virginia Connect

Today's Charleston Gazette features an article on a new health care demonstration project, West Virginia Connect, funded by a $36 million federal Health Resources and Services Administration (HRSA) grant.

The article indicates that the funding will be for eight West Virginia primary care clinics to provide preventative care services to eligible health consumers for a flat $35 per month. The services will include unlimited doctor visits, immunizations and screenings, chronic disease management, and minor surgical procedures.

To be eligible to particpate a person must have a job, be between 19 and 64, and make less than $43,320 for a single person or $88,200 for a family of four. In return, participants have to let the state fold their medical data - blood pressure, blood sugar, etc. - into an anonymous 10,000-person database the state plans to use to make more informed choices as health-care reform unfolds.

The article indicates that the primary care centers involved say the project is intended to:

• generate useful information about uninsured West Virginians and cost-effective ways to treat chronic diseases;
• demonstrate lowered emergency room usage, hospital stays, and times when people don't show up for appointments;
• develop an electronic patient tracking system other centers can use;create a catalogue of best practices that help people take better care of their own health;
• help the health system get ready for 2014, when hundreds of thousands will be newly insured through federal reform.

This is the first I have heard about this demonstration project. Other than this Grantee Project Abstract at HRSA website, I was unable to find any additional information or links about the demonstration project online. The article indicates that the project is currently governed by a steering committee of the DHHR secretary, insurance commissioner, and director of the GO HELP office.