1. State of Tennessee Department of Finance and Administration Office of Inspector General

2. TennCare Tennessee’s version of federally funded program Medicaid
Healthcare for those who qualify – primarily low income or disabled
Funded by federal (65%) and state (35%) funds -- calculated using a formula (federal medical assistance percentage or FMAP) – considers the state’s average per capita income relative to the national average.

3. TennCare 1.4 million enrollees $12 billion annual budget
Tennessee population 6.75 million
22% of Tennessee population on TennCare

4. TennCare covers: Children under age 21 Women who are pregnant
Parents or caretakers of a minor child (The child must live in the home and be a close relative.)
Women who need treatment for breast or cervical cancer

5. TennCare also covers:
People receiving Supplemental Security Income (SSI)
People on Social Security Disability (SSD) (dually eligible)
A person living in a nursing home and has income that meets Federal guidelines
Persons receiving other long term care services that qualify

6. TennCare HELPS 53% of all births in Tennessee
50% of children in Tennessee
2,347,500 outpatient visits per year
roughly 6,431 outpatient encounters per day statewide

7. OIG vs. TBI Tennessee Bureau of Investigation
Office of Inspector General
TBI’s Medicaid Fraud Control Unit investigates PROVIDER fraud
OIG investigates RECIPIENT fraud

8. Office of Inspector General
Established via TCA § and §
July 1, 2004
Mission: to identify and investigate persons who commit TennCare fraud or abuse; to coordinate efforts with other agencies; to recover money owed to the state.

9. Investigations Civil Criminal Complaints received
Triage of information
Initial investigation
Determines whether indications of intent
Processes civil cases with no criminal intent
Process civil restitutions
Conduct administrative hearings if requested
Special Agents investigate, obtain, document evidence of crime
Present for prosecution
Arrest
Follow case to completion
Process criminal restitutions

10. Our metrics
Accurate
Timely
Thorough

11. Work alongside TBI MFCU and DID Judicial Drug Task Force Agencies
Department of TennCare
TN Health Related Boards
IRS
Managed Care Organizations
Other state and local agencies

13. Eligibility Fraud, TCA § 71-5-2601(a)(2)(A)
Provides false information regarding:
income
household composition
location of residence
resources or assets

14. Eligibility Fraud, TCA § 71-5-2601(a)(2) and (a)(3) is a Class D Felony
Unless the value of the property or services obtained meets the threshold set for a Class B or Class C offense under § Code Sec ″> , in which case the appropriate higher class shall apply. >$10,000 Class C felony >$60,000 Class B felony

16. Doctor Shopping, TCA § 71-5-2601(a)(1)(A)(iii) is a Class D Felony.
Any person, including a TennCare enrollee, is obligated to disclose to a medical professional from whom the person obtains a controlled substance, or a prescription for a controlled substance that the enrollee has received either the same controlled substance or a prescription for the same controlled substance, or of a similar therapeutic use, from another practitioner within the previous 30 days, and TennCare was used to obtain the benefits.

17. Drug Diversion, TCA § 71-5-2601(a)(5)(A), is a Class D Felony.
A person commits an offense who knowingly sells, delivers, or aids and abets any person in the sale or delivery of a controlled substance and used TennCare to obtain the drug.

18. Tennessee is proactive
One of a few states that actively investigate recipient fraud

19. Administrative (Civil) Division FY 2018
4,449 tips received
3,901 cases were opened; 3,662 were completed
Cases initially investigated in the Administrative Division within ninety days to determine whether civil or criminal

20. 65.98% admin cases were drug-related

21. Criminal Division FY18 Opened 126 criminal cases
Closed 216 criminal cases
137 arrests

23. Arrest Stats 81% were drug-related 67.6% were white females
41.6% were 31 to 40 years of age
24.8% were repeat offenders
Recently had two persons be charged with their 6th offense of Doctor Shopping

24. Case Adjudication

25. Since July 1, 2004 124,594 cases completed 2,869 arrests
$4.6 million in criminal restitution ordered
$3 million in civil restitution ordered
$3.8 million returned to TennCare’s general fund
$190 million in potential savings resulting from 51,936 recommended terminations

26. TRENDS Increase in self-employed providing false income information
Decline in diverted pills

27. Strategies Hiring agents regionally
Metrics measuring accurate, timely, and thorough investigations
Strengthen eligibility expertise and sustainability of OIG

28. Case examples Returned to Tennessee on December 1, 2017
20 counts of Doctor Shopping in 4 counties
Treated on 34 occasions by 32 practitioners from February 2, 2016 to May 6, 2016
Oxycodone, hydrocodone, tramadol
Photos historical before/after drug abuse
Escaped authorities by residing under aliases in two shelters in Kentucky and Ohio
Relinquished her rights as a mother of a young son to another shelter resident
Arrested in Ohio
Son reunited with family members

29. TennCare fraud and theft over $250,000 (a class B felony)
Using her mother’s Tennessee address, Mississippi resident Cavitt-Burks enrolled her children and herself in TennCare from 2011 to 2016
She was a beneficiary of both Mississippi and Tennessee food stamps

30. Operation Kudzu
29th JD of West TN Violent Crime and Drug Task Force
Under direction of DAG Danny Goodman
94 fraudulent prescriptions
Morphine, hydrocodone, oxycodone, Xanax, gabapentin
Street value $292,650
Two of thirteen arrests

32. Carroll’s daughter had been enrolled in a Mississippi school since August 13, 2007
During investigation, daughter at age 16 had not been in school for two years
US Marshals’ Gulf States Task Force, Shelby County Sheriff’s Department, and OIG arrested Carroll on three counts of TennCare Fraud and theft of property of over $10,000 ($32,000), Class C felony

34. TennCare recipient
Worked for Dentist in Montgomery County
Forged 139 prescriptions for herself, her boyfriend, and boyfriend’s daughter
Hydrocodone and oxycodone
Sold prescriptions at a bar in Houston County
Said it was in order to keep a roof over her head and food for her child
Arrested July 17, 2017 for 31 counts of TennCare fraud and 25 counts of obtaining drugs by fraud
Pled to 7 counts of TennCare fraud, 2 years incarceration

35. Failed to report income from contract job with law firm from 2008 to 2013
Income limitation was $69,636 for her household composition
Her bank records documented her income at approximately $532,868
With assistance of Metro Police Department Midtown Precinct, Harden was arrested for TennCare fraud of approximately $18,800, a Class C felony

37. Obtained TennCare benefits for her and her child
Her child never resided with her
Child was adopted at birth and living in New York
Arrested for TennCare fraud and theft of services over $10,000
Pled to both counts on November 6, 2017
Sentenced to five years of probation
Ordered to pay $31,460 in restitution to TennCare

38. Patricia Simpson would obtain prescriptions for Subutex
She would provide Subutex and other contraband to an officer where Brad Simpson was incarcerated
Telephone calls corroborated the suspicions
Collaborative investigation with Putnam County Sheriff’s Department resulted in both Simpsons and others’ arrests.

40. Hotline Number: (800)
Main Line: (615)