Plan would force people to report TennCare fraud
NASHVILLE (AP) — Gov. Phil Bredesen and Tennessee lawmakers get calls nearly every day about people cheating to get TennCare benefits.
Some get benefits even though they live out of state. Others enroll in the program despite access to private insurance. Doctors submit claims for providing medical care to someone they suspect doesn’t qualify.
Bredesen hopes to use those citizen complaints to the state’s advantage by forcing Tennesseans to report people they suspect. If they don’t, they could be charged with a Class A misdemeanor, which carries a fine of up to $5,000.
“I don’t know how many conversations I’ve had with people over the last year who have said they know of someone improperly getting services,” Bredesen said. “We’re saying, ‘Help us out a little bit.'”
The new penalty is one part of the governor’s plan to reform TennCare, the state’s financially troubled health care program for poor, disabled and uninsured people.
TennCare costs $7.3 billion a year; the federal government pays two-thirds of the cost and state government the rest.
An independent report said the state cannot afford to keep TennCare as it now exists, but it also said fraud and abuse are not significant factors in the program’s rising costs.
Bredesen’s plan, introduced last week to legislators, calls for the creation of a new TennCare Office of the Inspector General. It would be separate from the TennCare bureau and have the authority to investigate all civil and criminal fraud and abuse.
The fraud unit will be designed to “get it out of the bureaucracy of TennCare, … give it a law enforcement flavor — making sure it’s got the tools and training that law enforcement people have — and really turn them loose on it,” Bredesen said.
“We’ll look up in a couple years, and I hope we’ll have eliminated a lot of fraud,” the governor said. “When you show you’re serious about it, a lot of people who might have considered lying to get on TennCare may not do it because we’re putting some consequences in there.”
The state plans to allocate $4 million for the program — $3 million in federal funds and $1 million from the state — to create at least one new district attorney position in Nashville to prosecute criminal cases, and two or three people in the state attorney general’s office to work on civil recoveries.
“We may be back to say this isn’t enough,” said Finance Commissioner Dave Goetz, whose office will oversee the fraud unit. “We’re (just) trying to get it started this year.”
Legislation authorizing some of Bredesen’s proposed changes will begin working its way through the General Assembly’s committee system this week.
Under the bill, doctors also would face stiffer penalties — an increase to $25,000 from $10,000 — if they submit claims for a person they suspect fraudulently obtained TennCare coverage.
The Tennessee Medical Association, which represents the state’s doctors, supports Bredesen’s effort to reform TennCare, but isn’t as sure about the plan to increase penalties imposed on health care providers.
“Physicians are there to provide the medical care, not to be the police unit,” TMA spokesman Russ Miller said. “That’s not to say doctors in doctor/patient relationship don’t bear some responsibility, but when it comes to a $25,000 fine, that’s different.”
Enrollees also would be charged with a felony for underreporting or failing to report income to TennCare that could affect their eligibility.
Sen. Ron Ramsey applauds Bredesen’s effort, adding that he constantly is approached by people — including members of his own family — with complaints about others taking unfair advantage of TennCare.
“I live five miles from the Virginia line, and I could easily name four or five people who have called me about people who live in Virginia but have TennCare cards,” the Blountville Republican said. “The only way we’ll learn who is doing it is through this kind of policing.”
Bredesen hopes the new Inspector General’s office will not only curb abuse of TennCare, but help rebuild public confidence in the program.
“People want to see some activity in (this) regard to give us some confidence,” he said. “Part of the thing that’s frustrating is it’s hard to say how big of a problem fraud is without having the kind of law enforcement mechanisms in place to go out and really investigate it actively.”
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On the Net:
TennCare Bureau, http://www.state.tn.us/tenncare/