A current issue in the state of TN is that of TennCare Fraud. TNCare is insurance offered by the state of TN for those eligible.
TennCare Medicaid is for Tennesseans who are eligible for a Medicaid program. You can apply anytime for TennCare Medicaid.
There are several different groups of people that may qualify. And, each group has different income limits. Some of the groups also have limits on how much you own-your "resources." These are things like bank accounts, cars, and land. The number of people who live in your household count too.
Some of the groups TennCare Medicaid covers are:
- Children under age 21
- Women who are pregnant
- Single parents or caretakers of a minor child (The child must live with you and be a close relative.)
- Two-parent families with a minor child living at home when one of the parents:
- Has lost their job or had their work hours cut, or
- Has a health or mental health problem expected to last 30 days (DHS will need proof from your doctor)
- Women who need of treatment for breast or cervical cancer
- People who get an SSI check (Supplemental Security Income)
- People who have gotten both an SSI check and a Social Security check in the same month at least once since April, 1977 AND who still get a Social Security check
- A person who:
- Lives in a nursing home and has income below $2,022 per month, or
- Gets other long term care services that TennCare pays for.
(tn.gov/tenncare)
TennCare is a great program for those that do not abuse the system, which is a rapid occurrence in the state of Tennessee. The main example of TennCare Fraud is what they call "doctor shopping." By "doctor shopping", I'm referring to patients who visit different doctors and pharmacies getting as many prescriptions filled with drugs that are easily sold on the street. There are many court cases filed daily for TennCare fraud involving "doctor shopping". Here are some of the briefs from those cases found on tn.gov/tenncare.
Rutherford Co. Woman Sentenced to Two Years for TennCare Fraud
Released on Thu, Aug 11, 2011 - 1:40 pm under
NASHVILLE – A Rutherford County woman charged with TennCare fraud has been ordered to serve two years in a Tennessee Department of Corrections (TDOC) prison facility.
The Office of Inspector General (OIG) today announced the conviction of Carman M. Reade, 22, of Murfreesboro. Reade pleaded guilty to one count of TennCare fraud and received a two year sentence, plus she must repay TennCare for her medical expenses while she was on the program, along with court cost and fines.
Reade was arrested by the OIG in March for using TennCare to obtain a prescription for the painkiller Hydrocodone and then selling a portion of the drugs. District Attorney General William Whitesell, Jr. prosecuted the case.
“Prescription drug trafficking has been a problem across the nation, but we are determined to eliminate this problem in the TennCare program in Tennessee,” Inspector General Deborah Faulkner said. “Enrollees who participate in selling drugs paid for by TennCare – and those who buy them – should understand this is a serious crime that we intend to prosecute to the fullest degree.”
The OIG, which is separate from TennCare, began full operation in February 2005 and has investigated cases leading to over $3.5 million paid in restitution and recoupment to TennCare, with a total estimated cost avoidance of over $173 million for the TennCare program, according to latest figures. To date, nearly 1,500 people have been charged with TennCare fraud.
Through the OIG Cash for Tips Program established by the Legislature, Tennesseans can get cash rewards for TennCare fraud tips that lead to convictions. Anyone can report suspected TennCare fraud by calling 1-800-433-3982 toll-free from anywhere in Tennessee, or log on to www.tn.gov/tnoig and follow the prompts that read "Report TennCare Fraud."
Bradley County Woman Charged with TennCare "Doctor Shopping"
Released on Mon, Aug 08, 2011 - 2:51 pm under
NASHVILLE – A Bradley County woman is charged with TennCare fraud involving “doctor shopping,” or using TennCare to go to multiple doctors in a short time period to obtain controlled substances.
The Office of Inspector General (OIG) with assistance from Bradley County Sheriff’s Officers today announced the arrest of Melissa Cronan, 45, of Ocoee. She is charged with eight counts of fraudulently using TennCare to obtain controlled substances by “doctor shopping.” Cronan failed to disclose to her doctor that she had seen other physicians within a 30-day period and received prescriptions for the same or similar controlled substances, with the clinical visit being paid for by TennCare.
"Physicians across the state have a taken a central role in cracking down on ‘doctor shopping’ in TennCare,” Inspector General Deborah Y. Faulkner said. “Before the law was passed, their hands were tied – but now they are quick to let us know about a person trying to abuse TennCare in this manner.”
TennCare fraud involving doctor shopping is a Class E felony carrying a sentence of up to two years per charge in prison. District Attorney General Steven Bebb is prosecuting.
The OIG, which is separate from TennCare, began full operation in February 2005 and has investigated cases leading to over $3.5 million paid in restitution and recoupment to TennCare, with a total estimated cost avoidance of over $173 million for the TennCare program, according to latest figures. To date, nearly 1,500 people have been charged with TennCare fraud.
Through the OIG Cash for Tips Program established by the Legislature, Tennesseans can get cash rewards for TennCare fraud tips that lead to convictions. Anyone can report suspected TennCare fraud by calling 1-800-433-3982 toll-free from anywhere in Tennessee, or log on to www.tn.gov/tnoig and follow the prompts that read "Report TennCare Fraud."
Gibson County Woman Charged with TennCare Fraud
Released on Fri, Sep 16, 2011 - 10:51 am under
NASHVILLE – A Gibson County woman is charged in Madison County
The Office of Inspector General (OIG), with assistance from Humboldt and Madison County
She is charged with two counts of TennCare fraud in a Madison County
“A TennCare card for one member of a family is not a ticket to benefits for everyone,” Inspector General Deborah Y. Faulkner said. “Children whose families can’t provide healthcare insurance deserve a healthy start, but the full array of benefits is not extended to adults, especially those who aren’t eligible for the program.”
Fraudulently obtaining TennCare medical benefits is a Class E felony that carries a maximum penalty of two years in prison per charge. District Attorney General Jerry Woodall will prosecute.
The OIG, which is separate from TennCare, began full operation in February 2005 and has investigated cases leading to over $3.5 million paid in restitution and recoupment to TennCare, with a total estimated cost avoidance of over $173 million for the TennCare program, according to latest figures. To date, nearly 1,500 people have been charged with TennCare fraud.
Through the OIG Cash for Tips Program established by the Legislature, Tennesseans can get cash rewards for TennCare fraud tips that lead to convictions. Anyone can report suspected TennCare fraud by calling 1-800-433-3982 toll-free from anywhere in Tennessee
I agree with you TennCare is a great program, but unfortunately there are a lot of people that are abusing the system. I am glad that the physicians are working with OIG on this issue that will make the process a little bit easier and quicker for the investigator.
ReplyDeleteTennCare is great for those that need insurance and can't afford to get it on their own. I believe that for the elderly that are on a fixed income the help should be unlimited. For others I think that the aid should be limited. I understand the instances where people lose their jobs or young mothers that need it for their children. However it should not be a permanent aid which they should get for several years unless there is a serious health condition. It goes hand and hand with the welfare system. It is my opinion that it should not be a permanent but only an aid to help people to get on their feet. Also if the penalties were stiffer that would cut back also. I say give the people found guilty of misusing the aid a minimum of 5 years. That would be a good way to deter the fraud. Its not fair to the one's that have to pay for insureance nor the people that really need the help.
ReplyDeleteJanise Wicks