TennCare blocks 3 top drug prescribers in fight against fraud, abuse
Written by Duane W. Gang and Brian Haas
Apr. 21, 2012

Three of TennCare’s top 10 prescribers of commonly abused mental health and pain drugs have been blocked from filling prescriptions through the state’s health-care program for the poor and uninsured.

In a 22-page letter and report to a U.S. senator investigating the over-prescribing of prescription drugs in the federal Medicaid program, TennCare Director Darin Gordon outlined the steps under way to cut down on fraud and abuse, including blocking the three prescribers.

“We agree that inappropriate prescribing is a serious problem that can result in patient safety concerns and increased costs to the healthcare system,” Gordon wrote in the March letter to U.S. Sen. Charles Grassley, R-Iowa.

“For this reason, TennCare has invested a great deal of effort to develop a multi-faceted approach to ensure that medications are used appropriately within our program.”

The letter came in response to Grassley’s request in January for additional information on how Tennessee monitors and investigates fraud and abuse.

Grassley sought answers to a dozen questions after Tennessee reported the top 10 prescribers of eight antipsychotic and pain medications.

In the letter, Gordon said TennCare routinely reviews prescription data and shares it with managed care organizations. Among the safeguards, Gordon cited a controlled substance database and a “lock-in” program, which restricts suspected drug seekers to a single pharmacy.

Overall, prescription drug use within TennCare has dropped from 2.6 million prescriptions in 2005 to 1.2 million today, Gordon told Grassley.

In addition, Gordon noted that Gov. Bill Haslam has introduced legislation to create a multi-agency effort to address fraud and abuse of controlled substances. It would include expanded access to the controlled substance database and more severe penalties for failing to report fraud and abuse.

TennCare blocks prescribers and refers them to the state Board of Medical Examiners for possible disciplinary action.

The three are not named in the letter to Grassley, but a TennCare spokeswoman released the names upon request Wednesday.

2 disciplined

The three — a physician, a physician’s assistant and an advanced practice nurse — are all from East Tennessee. Dr. Allen R. Foster and nurse Maimoune Wright have faced disciplinary action for over-prescribing drugs, according to the Board of Medical Examiners.

Foster is serving one year in prison after being sentenced last summer for health-care fraud and failure to file tax returns. His license has been revoked. Wright is awaiting federal trial on a charge of conspiracy to distribute prescription drugs. Her license has been suspended.

Wright could not be reached for comment. Her business listing was disconnected, and her home phone number is unlisted. The physician’s assistant named by the state, Thomas Esser, has not been disciplined. His home and business numbers were disconnected.

TennCare spokeswoman Kelly Gunderson said Wednesday that the three would have been blocked and referred to the medical examiners board regardless of Grassley’s inquiry. “We do have very thorough safeguards in place,” she said.

The state is actively looking to improve how it tracks and handles prescriptions, particularly as new drugs become available, Gunderson said.

But just because a prescriber is among the top 10 does not automatically mean something is wrong, she said. In his letter, Gordon reiterated concerns the state has long had about providing the top-10 lists to Grassley.

Other information, such as specialty, practice type and whether the drug prescribers follow evidence-based treatment guidelines, is needed, Gordon wrote. “To attempt to decipher the data without this additional insight may result in faulty conclusions,” he wrote.

In a statement Wednesday, Grassley said the state’s response reflects steps under way to reducing fraud and abusive prescriptions in Medicaid.

“But it’s hard to know whether the state has taken the right level of action,” he said. “While these steps sound productive, the state has blocked only a handful of prescribers from participation. I encourage states to conduct due diligence and block providers when necessary.’’