Lawmakers debate value of fraud unit

Lawmakers debate value of fraud unit

April 3rd, 2011 by Associated Press in News

NASHVILLE-TennCare fraud investigators had a record year in 2010, with 266 arrests and nearly $700,000 recovered. But the fraud unit cost $4.6 million to operate.

That has some lawmakers saying it should be self-supporting, with more arrests and more money recouped.

State Rep. Joey Hensley, R-Hohenwald, is a family practitioner who has turned in several people he believed were defrauding the system. He's also chairman of the TennCare oversight committee.

"With so much fraud I am honestly not too happy with the conviction rate," Hensley told The Tennessean. "I feel like there is a lot more of it going on than they are picking up."

But supporters say the numbers don't tell the whole story.

Federal law requires that each state offering a Medicaid plan maintain a Medicaid Fraud Control Unit, which investigates and prosecutes provider fraud. In Tennessee, that unit is part of the Tennessee Bureau of Investigation.

But federal regulations prohibit TBI from pursuing patient fraud in most cases. That's where the Office of Inspector General comes in.

Because investigators are dealing with individuals, and not doctors or institutions, the amounts collected are much lower, but the unit's value also is in the number of people it deters from committing fraud, supporters say.

"You have to have people that are willing to go out and unearth fraud of all sizes," said Jerry Martin, U.S. attorney for the Middle District of Tennessee. "If you don't have that, then people think they can get away with anything. Then you will have massive fraud done in small increments."

Since the Office of Inspector General fraud unit's creation in 2004, investigators have charged 1,382 people with TennCare fraud, the majority of which ended with a conviction or pretrial diversion, and recovered just over $3.7 million.

The unit has opened 132,515 cases in that time, but the vast majority of them were closed because fraud could not be proved.

Office of Inspector General spokeswoman Lola Potter said critics may not understand what it takes to obtain a conviction. Investigators have to be able to prove the fraud was committed knowingly, not simply by mistake.

Inspector General Deborah Faulkner said even when there is not a criminal case, the unit still can forward suspicious activity to the TennCare Bureau for review, as it has done in more than 48,000 cases.

Given that the state spends $3,656 on each of TennCare's 1.2 million enrollees, alerting TennCare about those cases potentially saved $173 million if all those people were removed from the TennCare rolls.

"To me it's about letting people know that Tennessee is not going to tolerate it," Faulkner said. "If you need it, you can have it, but if you are violating the rules and you are lying, we are going after you.

"I am a taxpayer, too, and I want to know that my money is going towards people who need it, not who are abusing it."