Friday, January 18, 2013

TEXAS LEGISLATURE: Health care bills aim to reduce fraud

TEXAS LEGISLATURE: Health care bills aim to reduce fraud

By Matthew Waller Scripps Texas Newspapers
Published Wednesday, January 16, 2013

go sanangeloAUSTIN — Texas lawmakers are looking at ways to cut down on billions in fraud and waste in Medicaid, health funding for the poor, they announced Wednesday.

The question is whether the proposed laws will discourage medical practitioners from operating or accepting Medicaid as payment, a Texas Tech professor said.

Medicaid fraud and waste cost Texas $6 billion from 2004-11, lawmakers said Wednesday.

Sen. Jane Nelson, R-Flower Mound, and chairwoman of the Senate Committee on Health and Human Services, plans to tackle that number with two pieces of legislation aimed at reducing Medicaid fraud and improving Medicaid services based on quality of care.

"It's depressing," Nelson said of the reports of Medicaid fraud. "I feel like we're playing Whac-A-Mole. We have one problem uncovered, and we try to deal with it, and then we see another one emerge. … We have to assume our responsibilities and head off some of these problems before they begin. … It's infuriating to hear report after report of the kind of abuses that are taking place."

Earlier this month, for example, the attorney general announced a $36 million settlement with pharmaceutical companies Pfizer and Endo on claims that the firms overcharged Medicaid for drugs.

Her legislation, in SB 8, would direct the Health and Human Services Commission to develop a program to identify red flags to handle abuses before they add up into the millions, she said.

SB 8 would also clarify that providers are ineligible for Medicaid when a court finds a provider liable for Medicaid fraud. It would also permanently exclude providers that have been debarred or excluded from other state of federal health care programs because of fraud or injury.

The points on ineligibility concerned Helen Morrow, an associate professor of social work at Texas Tech University who has worked for 30 years with health care and mental health. She expressed concern that permanently banning providers who are found to defraud the system — without the opportunity to reform their behavior — will further erode the state's Medicaid provider base.

"We've lost so many people in the nursing home business," Morrow said.

Nelson's bill would also strengthen the prohibitions against soliciting Medicaid clients, the senator said.

By solicitors she meant "people who are hanging out in front of elementary schools approaching mamas saying, 'Would you like braces on your child? We'll do it for free.' I'm talking about people who pass out Wal-Mart gift cards saying … 'If you come to this dentist, we'll give you a gift card," Nelson said.

Other provisions in the bill would put the Medical Transportation Program into a managed care setting and cutting down on inappropriate use of ambulances for nonemergency transports.

Managed care is an administrative system designed to eliminate redundancies and reduce the cost of care, in contrast to unrestricted fee-for-service medical care.

The other bill that Nelson announced, SB 7, would put practices into place that would reward the quality of medical treatment.

"The more you treat a person, the more money you get" has been the dynamic for Medicaid payment thus far, Nelson said. "We're changing that and focusing on outcomes and rewarding people, providers, who are providing quality outcomes to individuals who need our services."

SB 7 would redesign long-term care to accommodate a fast-growing senior population.

The bill would strengthen requirements ensuring that "quality-based payment initiatives apply in managed care" and expand managed care throughout Medicaid, including in nursing facility services.

Texas has the largest senior population in the country, with the number of Texas citizens 60 and older at 14 percent of the population, projected to grow to 20 percent by 2040, Nelson said.

Lt. Gov. David Dewhurst, the head of the Senate, showed his support for both bills, standing with Nelson at the announcement.

He said Medicaid is crowding out other priorities such as transportation and public safety because of ballooning costs in the program.

Since the 2002-03 biennium, Medicaid costs have doubled, Dewhurst said.

"We talk quite a bit about the strong economy in Texas and our financial condition, but I want to talk this morning about what I think is an obligation of government to reach out and help those people in our society who truly cannot help themselves — the elderly, frail, disabled," Dewhurst said.

"When you defraud the system, you are stealing from the taxpayers, from the children, from the poor, from the elderly and Texans with disabilities," Nelson said.

Matthew Waller is assigned to cover the 2013 Legislature for Scripps Texas Newspapers and works in Austin. Contact him at or follow him on Twitter, @waller_matthew.