TennCare doctor-shopping is fraud, bad medicine

TennCare doctor-shopping is fraud, bad medicine

July 21st, 2009 by Todd South in News

Shopping for a doctor may be a good idea when you're entrusting someone with your health.

"Doctor shopping," however, is a crime.

According to authorities, "doctor-shopping" -- when patients visit several doctors to acquire multiple prescriptions for various drugs -- is an ever-growing problem in Tennessee. In the last year, authorities have investigated 75 doctor-shopping cases in Tennessee and six in Hamilton County, according to the office of the Tennessee Inspector General, which handles such cases involving TennCare.

Office of the Inspector General


Year Arrests

2005 157

2006 203

2007 240

2008 264

2009* 103

*Year to date

Source: Tennessee Office of Inspector General


To report TennCare fraud, call 1-800-433-3982.

And it's only one type of fraud that's affecting TennCare patients and providers, Tennessee Inspector General Deborah Faulkner said.

In 2005, investigators arrested 157 people on fraud charges; last year they arrested 264. At least 14 area residents have been arrested this year on charges related to TennCare fraud, authorities said.

Residents of Hamilton, Franklin, Sequatchie and Coffee counties also have been indicted on doctor-shopping charges, records show. Six Coffee County residents were arrested in March and charged with selling prescription painkillers to undercover agents.

TennCare is the state's managed-care program established in 1994 to extend Medicaid coverage to state residents who otherwise would not receive it.

Since 2005, the inspector general's office has recouped $1.6 million from fraud cases. The Tennessee Bureau of Investigation has identified more than $200 million in Medicaid or TennCare fraud since 1990.

The rise in cases can be attributed to a statewide crackdown combined with a public more involved in reporting fraud both by TennCare enrollees and providers, Ms. Faulkner said.

Among the charges, investigators find fraudulent or altered prescriptions, TennCare recipients who have moved out of state but still use the system and doctor shopping. Some shoppers are addicted to prescription drugs; others sell their extra pills illegally for profit, investigators say.

People scamming TennCare not only cost the system money, but they clog up an already-burdened health care system, Ms. Faulkner said.

"When (doctors) have to deal with those individuals, it takes away from the people with real emergencies," she said.

Gov. Phil Bredesen created the Office of Inspector General to focus investigations on enrollees who try to defraud TennCare.


Offices near state lines, such as Chattanooga, are most likely to see fraud cases involving nonresidents using TennCare, officials said.

"Living in Hamilton County, it's something we deal with every day," said Kelly Dempsey, interim district director of investigation for the Department of Human Services.

Ms. Dempsey refers cases of TennCare fraud to either the TBI or the inspector general. Her work, she said, involves welfare or food stamp fraud, something that often runs parallel to TennCare fraud.

But it's not only TennCare enrollees committing fraud. A group of TBI agents focuses on provider fraud -- doctors, pharmacists or other medical professionals who take advantage of the system by overprescribing or selling medications.

TBI Special Agent in Charge Robert Schlafly heads the agency's Medicaid fraud control unit, which handles TennCare provider fraud cases, patient abuse claims and other aspects of crime involving Medicaid.

"In our opinion, it comes down to greed, and the government is generally an easy target," Mr. Schlafly said.

He said providers often tell him the government isn't paying them enough so they're just "making it right."

Much of the TBI and the inspector general's work is based on tips from patients, employees or residents who suspect someone is taking advantage of the system.

Sixty-one percent of cases reported to the inspector general come through the office's phone line, officials said, while the rest come by way of mail, e-mail and the agency's Web site.

"People get very ticked off at this," Ms. Faulkner said. "They work every day, they have insurance, pay their premiums and then see someone on TennCare abusing it, and they do the right thing and they want to report it."