Monday, December 3, 2012

Guilty ’til Proven Innocent: New Medicaid Fraud Rules Will Bully Doctors’ Offices

Physicians fear new rules adopted by the Texas Health and Human Services Commission (HHSC) Office of Inspector General (OIG) could threaten innocent practices and cut off access to care for thousands of Texas Medicaid patients. The new rules cast every Medicaid billing error as a possible target for fraud-and-abuse prosecution without due process.

Glenn Wood, MD, knows all too well about unjust fraud investigations, as he is a current victim of overreaching OIG scrutiny. Dr. Wood established six Carousel Pediatrics clinics that provide care for 40,000 Medicaid children in Central Texas. Last fall, OIG reviewed a fraction of Carousel Pediatrics’ patient records spanning from 2007 to 2011 and informed Dr. Wood he owed the state $18 million for overbilling and $4 million in penalties.

“I have a clear conscience, and I know our clinics’' billing mistakes were unintentional,” Dr. Wood told Texas Medicine magazine. “The problem is OIG doesn’t seem to be able to discern between good practices and bad practices. They just look at the numbers and go after groups that see a large volume of Medicaid patients.”

Even after review of his records by multiple outside sources showed no indication of fraud, Dr. Wood has yet to receive full payment from the state for services to Medicaid patients. As a result, he was forced to close three clinics in the Rio Grande Valley, lay off 20 percent of his staff, and temporarily close an Austin clinic.

Dr. Wood is not alone in his ordeal. Kaufman pediatrician Charles Turner Lewis, MD, battled fraud allegations by OIG from 2005 to 2008. After years of fighting the allegations, a judge ruled in Dr. Lewis’ favor.  The persecution took an emotional and financial toll on Dr. Lewis, who ended up draining his savings and retirement, and taking out a second mortgage on his home to keep caring for his patients.

Upon learning how the more stringent rules will increase fraud accusations against physicians, Dr. Lewis said, “Physicians will not want to come to Texas, thereby decreasing access to care, and physicians will have less control over the practice of medicine, placing it in the hands of bureaucrats and destroying the quality of our medical system.”

“It’s disheartening,” says John Holcomb, MD, chair of the Texas Medical Association’s (TMA’s) Select Committee on Medicaid, CHIP, and the Uninsured, who signed TMA’s comment letter opposing the OIG rules. “They allow OIG to proceed with payment holds and essentially impound money from doctors without providing appropriate due process.”

Without due process protections and other important changes in the rules, Dr. Holcomb wrote, “The pervasive fear among physicians that they will be incorrectly accused of fraud, waste, or abuse, or denied meaningful recourse in a fraud investigation will further contribute to the decline in physician participation in Medicaid.”

For the complete story, read the December issue of Texas Medicine magazine.

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