TennCare enrollees attempting to defraud the state's health-care system should know that TennCare's new fraud czarina is cracking down on prescription drug abuse. Last week, some 9,300 enrollees receiving "questionable finding" letters were given 14 days to respond.
The form letters were sent by Deborah Faulkner, TennCare's inspector general. Almost 8,000 were addressed to enrollees using pharmacies more than 100 miles from their homes to fill more than three prescriptions. The remainder of the notices were sent to enrollees using more than three pharmacies or four doctors to fill prescriptions within a 30-day period.
These actions, known as drug seeking and doctor shopping, have contributed to ballooning pharmacy costs in the health-care program. Despite savings from the formation of a pharmacy advisory board and preferred-drug list, pharmacy costs exceeded $2.1 billion last year, well above the $1.89 billion amount spent on higher education.
"The goal is to restore integrity to the health-care program," Faulkner said. "The honest people who need this assistance, we want them to have it. It's the people who are using up the money illegally that we're trying to catch."
Tennessee governor Phil Bredesen has long championed the need for a more aggressive fraud unit within TennCare as well as stiffer penalties for abuse. He established Faulkner's department in February, got fraud legislation passed in June, and hired 40 new investigators, attorneys, and medical professionals soon after.
With the uncertain future of TennCare, stopping fraud is vital. TennCare recipients using distant pharmacies during the period from April to June accounted for more than 155,000 prescriptions, costing TennCare almost $15 million.
A survey of counties with possible pharmacy abuses listed Shelby County as number one -- not necessarily due to the number of abusers but to an abundance of enrollees, said Faulkner. Of the 1.3 million Tennessee residents on TennCare, more than 230,000 live in Shelby County, accounting for 26 percent of the county's population.
Leading the list of most commonly prescribed drugs were narcotic pain relievers, sleep inducers, and antidepressants. Many of these drugs are habit-forming and may also have relatively high street resale value.
In addition to the letters sent to enrollees, 48 letters were sent to providers charging them with excessive billing.
"There are all types of fraud. People living outside the state come back and use TennCare services. Some people have access to private insurance but opt out and get on TennCare. Some may be obtaining the drugs illegally and selling them. All of those things are felonies. And it all boils down to greed," said Faulkner. "But it's not our job to judge people prematurely. If we determine that a law has been broken, we will prosecute."
Prior to this latest campaign, the fraud office compared wages reported by TennCare recipients to state wage reports. That investigation yielded 3,000 enrollees whose wages were at least $1,500 more than they reported. Some of those individuals agreed to be removed from the TennCare rolls, and others were required to repay the health-care program.
Last year, the Tennessee Bureau of Investigation and TennCare studied 30,000 cases and referred 10,000 enrollees for possible fraud. •