Office of Inspector General 1 TennCare Fraud Office of Inspector General (History and Mission) Manny...

Office of Inspector General 1

TennCare FraudOffice of Inspector General

(History and Mission)

Manny TyndallAssistant Inspector General

Special AgentCriminal Investigation Division

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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, 2011Source: 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, 2011Source: 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: 3942012: 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 AreaCITY 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, 2004OIG officially launched

independent of Bureau of TennCarereporting 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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InspectorGeneral

Organizational Structure

CriminalInvestigation

Division

Legal DivisionCriminal

&Civil

EligibilityIntegrityDivision

Drug Diversion

Team

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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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Criminal

Civil

Arrests – 1,950

Restitution & Arrests

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Types & Number of ArrestsAccess 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

80.6%

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Number of Arrests: Race & Gender

NOTE: Some individuals may have been arrested more than onceNOTE: 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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Hotline Number1 (800) 433-3982

Tenncare.Fraud@tn.gov

Law Enforcement

Providers

Anonymous

State Agencies

?

R x

Sources of Information

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Press Releases and Print Media

Briefings, Presentations, In-Service

Broadcast Media

Spread The Word

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Posters

English and Spanish

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Hotline Number: (800) 433-3982

Main Line: (615) 687-7000

TennCare.Fraud@tn.gov

http://www.tn.gov/tnoig

Media Releases; Statistics; Definitions;

How to Report Fraud.

Contact Information

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SUMMARYTennCare 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