WHAT’S HAPPENING:

On Thursday April 25, the Department of Health announced that due to its preliminary investigations in the scandal involving Managed Long Term Care plans using social adult day centers as enrollment centers and providing illegal incentives for people to join, they were suspending VNS Choice’s ability to accept new members temporarily.

VNS Choice is one of the largest MLTCs in the state. The admission that they were engaging in fraudulent enrollment to cherry pick healthy consumers is extremely worrisome.

The New York Times published an article yesterday on the matter, entitled “State Suspends Enrollment in Adult Care Plan Amid Fraud Concerns.”

Click here to read the article at the New York Times website.

 

This scandal highlights why, for reasons other than the integrity of the model, that A) managed long term care companies must not be allowed to serve as fiscal intermediaries (FIs), and B) a state Certification or other process is necessary to ensure accountability and adequacy within the FIs operating within the state.

The new system can prove incredibly effective; however, controls must be in place. While the social adult day centers were not directly operated by VNS Choice, the apparent collusion – with social adult day centers promising casino visits and free lunch in return for signing up with particular plans – speaks to the potential for abuse. If MLTCs operate the Fiscal Intermediaries, as many, including VNS Choice, propose to do, the potential for this type of abuse is raised astronomically.

The potential for this abuse, among FIs that would be operated by plans or among unscrupulous FIs that might seek to enter into agreements with plans such as those that were allegedly entered into between the social adult day centers in question and VNS Choice, is even greater given the lack of any certification or licensure from the state. CDPAANYS continues to call for Certification by the state of Fiscal Intermediaries, to ensure that there are adequate standards in place to, among other things, protect against this type of fraud. Such standards will also allow the state hold FIs accountable, because they will have the ability to pull the Certification.

It appears that VNS Choice and the centers in question acted poorly here. We must act in other areas to prevent such abuses before they occur.

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