6 Modern Healthcare | August 12, 2019
NORTHEAST
Alliance for Better Health
forms IPA with insurer to
address social risks
The Alliance for Better Health, a
convener of providers and community
groups, and managed-care organiza-
tion MVP Health Care have partnered
to i nvest $800,000 over t wo yea rs i n not-
for-profit community organizations
around Albany, N.Y.
The new partnership is called
Healthy Alliance Independent Prac-
tice Association. Unlike other IPAs in
the U.S., it doesn’t involve physicians.
Rather, the partnership focuses solely
on helping community-based organi-
zations provide services that address
social determinants of health, said Dr.SOUTH
Baylor Scott & White wins
FCA case over upcoding
Jacob Reider, CEO of the Alliance for
Better Health.
Providers have increasingly re-
lied on community-based organiza-
tions to address social determinants
of health even as they struggle with
unstable funding sources. Not-for-
profits depend heavily on grants from
states and charities, which aren’t sta-
ble, Reider said. The IPA heard from
organizations that said they had to
change their priorities when funding
changed, which made it difficult to
achieve long-term goals.
The alliance will use insurer invest-
ments, which Reider said “can persist
forever.”
MVP, with about 190,000 of its
700,000 members in Medicaid, is the
first insurer to invest funds.Geisinger names former
population health officer as
chief nursing officerGeisinger Health placed its former
chief population health officer, Janet
Tomcavage, in the role of chief nursing
executive.
Tomcavage, who has been with Dan-
ville Pa.-based Geisinger since 2014,
was touted as a “pioneer in population
health and advanced medical homes.”
“Nurses make a huge difference ev-
ery day in the lives of our patients, and
this new position reflects our ongoing
commitment to nurses and to their
professional growth,” Dr. Jaewon Ryu,
Geisinger’s CEO, said in a statement.
Tomcavage most recently helped
launch Geisinger at Home, a home-
based care model for medically com-
plex patients.SOUTH
Louisiana picks 4 companies
for Medicaid managed careFour companies have been chosen to
manage the care of 1.7 million Louisi-
ana Medicaid patients.
Louisiana health department offi-
cials said that the contracts, worth bil-
lions, will go to AmeriHealth Caritas
Louisiana, Community Care Health
Plan of Louisiana, Humana Health
Benefit Plan of Louisiana and United
Healthcare Community Plan. Terms of
the deals remain to be negotiated.
Louisiana contracts with man-
aged-care companies to oversee ser-
vices provided to 90% of its Medicaid
recipients. Two current Medicaid
managed-care organizations, Lou-
isiana Healthcare Connections and
Aetna Better Health, lost out on new
contracts. Louisiana Healthcare Con-
nections covers about 26% of the state’s
Medicaid managed-care patients.
Company lobbyist Randal Johnson
says the organization will file a formal
protest of the contract awards. Mean-
while, some lawmakers are question-
ing the wisdom of reshuffling one-third
of the program’s patients to new plans.
The current deals, negotiated by for-
mer Gov. Bobby Jindal’s administra-
tion, expire Dec. 31. The new contracts
will begin in January.Baylor Scott & White Health beat a False Claims
Act whistleblower suit claiming the Texas healthcare
giant wrongly billed Medicare for more than
$61.8 million over seven years. U.S. District Judge
David Ezra in Texas dismissed the whistleblower’s
complaint, which alleged that a Baylor executive
created an upcoding scheme to systematically
overcharge Medicare.
The judge said the whistleblower couldn’t show
that the hospitals were intentionally submitting
false claims. He added that the alleged scheme was consistent with the
government’s own “encouragement” to use the billing codes to glean as
much reimbursement as possible from Medicare.
The FCA lawsuit was filed in 2017 and focused on two secondary billing
codes: for “complication or comorbidity” (CC) and “major complication or
comorbidity” (MCC). Those codes can boost reimbursements anywhere
from $1,000 to $25,000. The whistleblower said Baylor’s former system vice
president for physician documentation and coding, Dr. Anthony Matejicka,
trained and pressured doctors to amend their claims with these codes.
Ezra concluded that Matejicka did indeed “spearhead” an effort to boost
payments with these secondary codes, and that Matejicka intended to
increase the number of upcoded claims. But that’s as far as the strategy
went, and the whistleblower’s case fell apart because it didn’t show
intentional fraud, Ezra said. —Susannah Luthi