Transcript office of inspector general

TennCare Fraud
Office of Inspector General
(History and Mission)
Manny Tyndall
Assistant Inspector General
Special Agent
Criminal Investigation Division
Office of Inspector General
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National Statistics
2011: 4.02 billion prescriptions written  2010: 16 million Americans reported
nonmedical use of prescription drugs –
 Prescription pain killers
now leading cause of
accidental death in U.S.
Source: www.whitehousedrugpolicy.gov/prescriptiondrugs/index.html
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Deaths by Age: Opioid Pain Relievers vs.
Illegal Drugs (National Statistics 2010)
Source: CDC, Morbidity and Mortality Weekly Report, 60(43): 1489, 2011
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Deaths from Opioid Pain Relievers vs.
Illegal Drugs (National Statistics 2010)
Source: CDC, Morbidity and Mortality Weekly Report, 60(43): 1489, 2011
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Tennessee Statistics
18+ million prescriptions were written
for controlled substances in 2012.
Among top states in the nation for:
 prescriptions written;
 Hydrocodone & Oxycodone sales;
 drug overdose deaths
Neonatal Abstinence
Syndrome
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Top 10 Prescriptions in TN (2012)
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All Prescriptions in TN (2012)
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Overdose Deaths in Tennessee (2011)
 1,062 drug overdose deaths
 TN 16.6 per 100,000
 US 12.9 per 100,000
 Middle TN: 2011: 394
2012: 424
 Nationwide: 16,500
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TennCare Statistics
 1.2 million people on TC (20%) –
Average annual cost of recipient
$3,656.00
 Budget for TC: 2012 - $9.4 billion
 Pharmacy budget: $733 million
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Pharmacies in Local Area
CITY
PHARMACIES
Nashville
133
Franklin
42
Clarksville
37
Dickson
13
Spring Hill
12
Ashland City
9
Fairview
9
Erin
9
Waverly
9
McEwen
9
Kingston Springs
4
Jackson
31
Memphis
207
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Illegal Prescription Drug Sales
 Hydrocodone (Lorcet; Lortab; Norco; Vicodin)
- sells for $6.00 - $8.00 each
 Oxycodone/Oxycontin (Percocet; Percodan; Tylox)
- usually $1.00 per mg
 Morphine sells for: 30mg - $30; 60mg - $45;
100mg - $60 (sometimes $1.00 per mg)
 Methadone $10 - $40 per dose
 Opana (Oxymorphone) $1.00 per mg
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OIG Launched
July 1, 2004
OIG officially launched
independent of Bureau of TennCare
reporting directly to the
Commissioner of Finance and Administration
focus on applicants/recipients
TBI Medicaid Fraud Control Unit (MFCU)
Providers
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OIG Mission and Goal
The mission of the Office of Inspector
General is to identify, investigate, and
prosecute persons who commit fraud
and abuse against the TennCare
program.
The goal is to save the State of
Tennessee and the TennCare program
money by finding fraud and abuse,
stopping it, and recovering monies
owed to the state.
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Health Oversight & Law Enforcement
The Office of Inspector General
functions as both a health oversight
and law enforcement agency and is
authorized to obtain pertinent health
information upon request.
TCA § 71-5-2609
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Organizational Structure
Inspector
General
Eligibility
Integrity
Division
Drug
Diversion
Team
Legal Division
Criminal
&
Civil
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Criminal
Investigation
Division
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Primary Criminal Case Types
 living out-of-state
 ineligible person(s) using benefits
 nursing home – estate cases

theft of services
 resource/assets
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Primary Criminal Case Types
drug diversion: 75 – 80% of cases
“Any criminal act involving a prescription drug”
 forged, altered prescriptions
 selling prescriptions
 obtaining a controlled substance by fraud
 sale of medication paid for by TennCare
 “doctor shopping”
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Restitution & Arrests
Criminal
Civil
Arrests – 1,950
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Types & Number of Arrests
Access to Insurance
55
Drug Diversion - Sale/Forgery
1287
Doctor Shopping
286
Ineligible Persons Using TennCare
20
Asset Diversion
7
Resource/Income
80
Out of State
32
Identity Theft
66
Aiding & Abetting
7
Child Not in Home
21
DEA Task Force
38
Falcon III & IV
48
Failure to Appear
3
Total Arrests
1,950
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80.6%
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Number of Arrests: Race & Gender
NOTE: Some individuals may have been arrested more than once
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Number of Arrests by Age
AGE
COUNT
16 - 20
68
21 – 25
215
26 - 30
294
31 – 35
326
36 - 40
257
41 – 45
213
46 – 50
158
51 – 55
125
56 – 60
80
61 – 65
53
66 - 70
20
71 - 75
8
76 - 80
2
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Sources of Information
Hotline Number
1 (800) 433-3982
[email protected]
Law Enforcement
Providers
Anonymous
?
State Agencies
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Spread The Word
Press Releases
and Print Media
Broadcast Media
Briefings, Presentations, In-Service
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Posters
English and Spanish
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Contact Information
Hotline Number: (800) 433-3982
Main Line: (615) 687-7000
[email protected]
http://www.tn.gov/tnoig
Media Releases; Statistics; Definitions;
How to Report Fraud.
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SUMMARY
TennCare fraud and more specifically prescription
drug diversion is a problem facing every county in
the state.
No one agency can be as successful as a number of
agencies working together.
We need to work together to combat TennCare
fraud -- especially prescription drug diversion.
If a person has ever committed TennCare fraud or if
they are now committing TennCare fraud (in state or
out-of-state), they can expect a visit from our office.
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QUESTIONS?
Criminal Investigation Division
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