The TennCare Office of Inspector General hit a milestone last month of the 1,000th arrest since establishing the unit in 2005. But in terms of money recouped from fraud, the lion’s share comes from doctors and pharmacists. And those cases are handled by a separate office in the Tennessee Bureau of Investigation.
The TBI Medicaid Fraud Control Unit has released its annual report. It identified or recouped $44 million over the last year. Since 2005, TennCare has taken in $175 million for provider fraud. Patients have coughed up just $2.5-million for illegal use of the program over the same period.
Bob Schlafly directs the TBI fraud unit. The office indicted just five providers last year after lengthy investigations.
“You know, ours are more long term. They typically take a couple of years and they may result in one arrest.”
Agents opened one case nine years ago. A pharmacist in Savannah was overbilling for unauthorized prescription refills. He didn’t plead guilty until last year and paid the state $20,000 in fines and restitution.
Included in the TennCare provider fraud unit’s annual totals are the so-called “global” settlements. Those include instances when drug manufacturers settle in multi-state agreements.
While the TBI handles provider fraud, the TennCare Office of Inspector General receives tips through its Web site for both patients and providers.
WEB EXTRA:
Information on the Medicaid fraud division’s 14 convictions last year:
1. Isaac Williams. Williams and a partner owned a business contracting with Mental Retardation Services (using TennCare funds) to provide services to mentally retarded individuals and other vulnerable adults. Investigation showed that these services were not provided. Williams pled guilty to one count of Misprision of a Felony in US Dist Court, Western district. He was sentenced to five years probation and fined $76,613 in restitution to the State. Also barred from future employment involving any fiduciary duties.
2. Kevin Douglas, MD Douglas was a physician in west TN who prescribed controlled substances with the knowledge that the meds would be sold on the street and that only prescribe drugs in exchange for a portion of the proceeds from the sales. He also billed the government for tests that he had not performed. He pled guilty in US Dist Court to one count of having knowingly and intentionally omitted reporting to the DEA the distribution of Hydrocodone. He was sentenced to time served (which amounted to one year and three months), placed on probation for 6 months, fined $1000 and had his medical license suspended.
3. Robert Williams PharmD. Williams owned a drug store in west Tn. Basically, he was billing TennCare for expensive drugs that were not authorized or delivered to patients, and was selling this inventory to other non-TennCare patients. He pled guilty in US District court to one count of submitting a false prescription to TennCare. He was sentenced to two years probation and one hundred hours of community service. He was fined $5,000 and ordered to pay restitution to TennCare in the amount of $15,121.72.
4. Stephanie Wilson, LDN Wilson, a licensed nutritionist, was charged with billing for services not rendered. She entered a guilty plea and was sentenced to 3 years probation, $1200 restitution, and 150 hours of community service.
5. Sanford Myers, MD Myers was basically a “pill mill”. He had written narcotic prescriptions to non-patients, received money and cocaine in exchange for prescriptions etc. He pled guilty in US District Court to one count of conspiracy to possess with the intent to distribute a schedule II controlled substance. he was sentenced to 13 years in federal prison and a $100 fine.
6. Larry Cummings. Cummings engaged in a conspiracy with a doctor to obtain narcotics for illegal distribution. He pled guilty to one count and was sentenced to 84 months in federal prison and 3 years probation upon release.
7. and 8. Charles and Christopher Ridenour. Both brothers were charged with conspiring to obtain and distribute narcotics in conjunction with a doctor. Christopher was sentenced to 134 months in federal prison and 3 years probation upon release. Charles’ sentence has yet to be recorded in our files.
9. and 10. Marilyn Watts, MD and Darryl Dempsey. Dr. Watts co-owned a rehab company that paid money for patients referred to them, treated patients with unlicensed personnel and without supervision and various other schemes. She pled guilty in US Dist Court to one count of Conspiracy to Commit Wire Fraud, Health Care Fraud, Payment of Money for Referral of Patients. She was sentenced to 5 years probation with 12 months home detention, a court fee of $100 and restitution to CMS of $3,534,881. Dempsey was a consultant to the company and he pled guilty to similar charges. Because of his cooperation with the government he was sentenced to 18 months probation, a fee of $100 and restitution of $190,000 to CMS.
11. and 12. Michael and Robert Prince Also associated with the above rehab company, Michael Prince wa an owner of a consulting services company that functioned as a billing agency for the rehab company. He pled guilty to one count of a 63 count indictment and was sentenced to 25 months in federal prison, assessed $100 and ordered to pay restitution to CMS of $4,108,226.76. Robert Prince was a bookkeeper in Dallas TX, employed by the consulting firm above, who did bookkeeping for the rehab company. He pled to one count of Conspiracy to Launder Money and forty counts of Money Laundering and Aiding and Abetting. He was sentenced to federal prison for 5 years and 3 months, a fee of $4,100, and restitution of $420,000 fo CMS.
13. Teresa Birdsong, RN An assistant director of nursing at a nursing home, diverted narcotics from patients and used them herself. she pled guilty to one count of obtaining a controlled substance by fraud. She was sentenced to drug treatment, monthly drug screens, and fifty hours of community service in return for a deferment of prosecution.
14. John Ford. Former State Senator convicted of accepting money as a purported consultant for two different TennCare contractors. He was sentenced to 14 years in federal prison.
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