Physicians Caught In Bureaucratic Nightmare While Medicaid Children Suffer, USA

Main Category: Medicare / Medicaid / SCHIP
Also Included In: Pediatrics / Children's Health
Article Date: 15 Jul 2009 - 3:00 PDT

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While only two-thirds of Texas doctors treat Medicaid patients, a Texas government agency is using tactics that might turn more doctors away from the program, according to the Texas Medical Association (TMA).

In one recent example, Texas' Office of Inspector General (OIG), a Texas Health and Human Services Commission (HHSC) agency, told San Antonio physician Milissa Aldridge, MD, that she can treat Medicaid patients only if she pays the state nearly $1 million. The OIG monitors Texas Medicaid to prevent and reduce waste, abuse, and fraud. In dispute in Dr. Aldridge's case are a clerical error and a misplaced letter from years ago.

For nine years, Dr. Aldridge practiced pediatric radiology in San Antonio - one of only 36 such specialists in the state - and cared for young Medicaid patients. But the OIG made her stop seeing Medicaid patients earlier this year, and demanded she repay the state $834,434.83. The OIG cites an administrative sanction she received 13 years ago when she chose to end her career as a pharmacist and become a physician. Because she chose to let her pharmacy license lapse to inactive status during medical school, Medicaid excluded her from participating in the program as a pharmacist. But she was unaware they had excluded her, so she did not report that on a Medicaid provider application in 2000. Unknown to her, the 13-year-old action meant she should not have participated in Medicaid all these years.

After the OIG banned her from Medicaid, Dr. Aldridge appealed for permission to see Medicaid patients again. The OIG first denied the request, then offered her this deal to entitle her to care for Medicaid patients: She could pay back the $800,000+ that Medicaid paid her for treating all those patients, or it would keep half of all her future Medicaid earnings until she repaid the full amount. Only by paying back what she had earned caring for Medicaid patients could she treat more Medicaid patients.

One TMA physician leader calls this extortion.

"If the [OIG] inspector general truly believed that this was fraudulent billing, it's his responsibility and duty to turn this case over to the attorney general for criminal prosecution," says John R. Holcomb, MD, chair of TMA's Select Committee on Medicaid, CHIP, and the Uninsured. "Instead, the office has sent Dr. Aldridge a letter demanding more than $800,000 as the price of letting her back in the program," he said.

TMA's Patient-Physician Advocacy Committee recently reviewed Dr. Aldridge's case. "Based on the information we heard from Dr. Aldridge and her attorney, it raises the concern of whether the OIG is functioning to protect the integrity of the Medicaid program or acting as a revenue generation mechanism," says Chair Robert H. Emmick Jr., MD. He adds that it raises "a question of the lack of common sense and proportionality for the issues that the OIG is addressing."

Because of the sanction, Dr. Aldridge lost her job with her medical group, Radiology Associates of San Antonio PA. She also lost her faith in Texas' Medicaid system. "You think you're doing the right thing, and then someone tells you you're not doing the right thing and are a criminal," she says in the July issue of TMA's Texas Medicine magazine.

Other doctors have faced similar OIG tactics. The OIG accused Charles Turner Lewis, MD, of overbilling in 2004 and 2005, and told him to fork over $439,109.67. Investigators at the Office of the Attorney General of Texas examined Dr. Lewis' charts and interviewed him and his staff for a week during the summer of 2007. Ultimately, the AG's office approved of Dr. Lewis' billing practices and information, so the OIG backed off.

Dr. Lewis' attorney, Hugh Barton, JD, says Dr. Lewis' story is encouraging because, "If physicians want to fight hard enough, they can be successful against the OIG."

Dr. Lewis has become an advocate for physicians' rights. His ordeal led to proposed state legislation to bring transparency to the way the OIG reviews physicians' Medicaid claims. The legislation would give physicians due process if accused of inappropriate activity. By bringing fairness to the process, the legislation also would enable the state to recruit more physicians and health care professionals to participate in Medicaid. But the legislation ultimately died along with many other bills in the final days of the 2009 legislative session.

Dr. Emmick worries the OIG's tactics send a message to Medicaid-participating doctors that they are at high risk of OIG scrutiny - which may intimidate more doctors to shy away from the program.

TMA physician leaders believe that the OIG should dole out harsh punishment only when a case merits it, instead of driving physicians out of the Medicaid program. Patients ultimately suffer the consequences, they say.

TMA is the largest state medical society in the nation, representing nearly 44,000 physician and medical student members. It is located in Austin and has 120 component county medical societies around the state. TMA's key objective since 1853 is to improve the health of all Texans.

Source
Texas Medical Association

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