State OIG Demands Back Medicaid Payments
Law Feature - July 2009
Tex Med. 2009;105(7):29-34.
By Crystal Conde
Milissa Aldridge, MD, becomes emotional when she talks about her career nowadays. What she's experienced would shake even the strongest physician.
For the past nine years, Dr. Aldridge has been a pediatric radiologist in San Antonio. She's one of only 36 in the state, according to the latest available Texas Medical Board data. What makes her even more of a rarity is that she treats Medicaid patients.
At least she did until she became the target of the Office of Inspector General (OIG), a Texas Health and Human Services Commission (HHSC) agency that monitors Medicaid to prevent and reduce waste, abuse, and fraud. It's demanding she repay the state more than $800,000 because of an administrative sanction she received 13 years ago after she decided to give up her career as a pharmacist and become a physician. That sanction means she's been ineligible to participate in Medicaid for all these years.
Since the OIG snared her in its net, Dr. Aldridge lost not only her job with her medical group, Radiology Associates of San Antonio PA, in March, but she also her faith in the Medicaid system.
"I started asking for advice early on in my medical career, and I was told not to take Medicaid patients," she said. "You think you're doing the right thing, and then someone tells you you're not doing the right thing and are a criminal."
Kicked out of Medicaid and unable to find work, the physician says she feels like a pawn in the OIG's quest to recoup money for Medicaid.
"Here we are as physicians thinking about the children when the state government is thinking about its money."
The Texas Medical Association's Patient-Physician Advocacy Committee reviewed Dr. Aldridge's case during an executive session in May. Robert H. Emmick Jr., MD, committee chair, says the case raises "a question of the lack of common sense and proportionality for the issues that the OIG is addressing. 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."
Dr. Aldridge is working with TMA to reach out to legislators to reform the OIG's recoupment practices. She and her attorney, Hugh Barton, JD, of Austin, are weighing their options in an attempt to free her from the OIG's noose.
Texas Medicine wanted to ask the OIG several questions about this case, but OIG staff chose to remain silent and not respond to our request for an interview.
The Nightmare Begins
Dr. Aldridge received her medical degree from The University of Texas Medical Branch at Galveston in June 1995. She ceased using her pharmacy license after her second year of medical school, but continued renewing it, inadvertently reporting that she met continuing education requirements.
That same year, a Texas State Board of Pharmacy audit revealed she hadn't completed the required amount of continuing education credit to maintain her pharmacist's license. She did not take the pharmacy courses because she had decided to go to medical school. She ultimately signed an agreed order with the pharmacy board and allowed her pharmacy license to lapse to inactive status. As a result, although she says she didn't know it at the time, the Medicaid program excluded her as a pharmacist in 1996. The pharmacy board never revoked her license.
The OIG says the Texas Department of State Health Services notified Dr. Aldridge of the exclusion in a certified letter in 1996. However, Dr. Aldridge doesn't remember getting the letter and has no record of it. The OIG told her that her husband signed for it, but she says he doesn't remember doing so.
"I knew nothing about this letter, and if I had known about it, I wouldn't have had a clue what it meant," she said.
Dr. Aldridge realized she was on the OIG's radar screen when another hospital at which she practiced, Foundation Surgical Hospital of San Antonio, went through the process of recredentialing her earlier this year. In January, the hospital discovered the OIG had flagged Dr. Aldridge. Once she heard something was amiss, she called the OIG for more information.
Dr. Aldridge says she attracted the OIG's attention because it determined she was responsible for 35 percent of Radiology Associates' Medicaid billing, a large volume attributable to her work at Christus Santa Rosa Children's Hospital, which serves a large indigent population.
"The OIG told me that caused the office to raise a red flag and to suspect the program's integrity may be suffering," she said.
At the time, an OIG employee told her she was under investigation for Medicaid billing based on her pharmacy license. The employee couldn't provide any more information and informed Dr. Aldridge it was too early to retain an attorney.
Unaware of exactly what she was up against, Dr. Aldridge wrote the OIG to clear up any inaccurate information about her pharmacy license and to request reinstatement in the Medicaid program.
She heard nothing until she received a letter from the OIG dated March 2 denying her request for reinstatement. The letter also informed her that the OIG wouldn't reconsider her request again until at least March 2, 2010.
Then on April 9, the OIG outlined for Dr. Aldridge its proposed settlement agreement and a reinstatement payment of $834,434.83, the amount the agency determined she owes for billing Medicaid while excluded from the program. The OIG offered to allow her back in Medicaid if she makes monthly payments to pay back the money or agrees to a "system recoupment" on 50 percent of her future Medicaid billings, which would be credited toward the total amount she owes until paid in full.
John R. Holcomb, MD, chair of TMA's Select Committee on Medicaid, CHIP, and the Uninsured, says the OIG's pursuit to recoup money from Dr. Aldridge is extortion.
"If the 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. 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.
Mr. Barton says Dr. Aldridge could have appealed the exclusion back in 1996, but the OIG did not give her any such opportunity in its March 2 letter.
Dr. Aldridge is surprised the Medicaid exclusion under her pharmacy license has any bearing on her participation in the program as a physician.
"I never dreamed that having a previous license put on inactive status would have been the basis for exclusion from Medicaid," she said.
Dr. Aldridge says officials could have caught her exclusion from Medicaid much earlier than they did.
She began practicing medicine in 2000 and submitted her Medicaid provider enrollment application to HHSC. On the portion of the form that asked if she had ever been excluded from a state or federal program, Dr. Aldridge checked "no," unaware that she indeed had been excluded from Medicaid.
At the time, HHSC hired an outside enrollment vendor to process the applications. The vendor had an obligation to check Dr. Aldridge's Medicaid eligibility status and to identify if she'd been excluded. According to Dr. Aldridge, the vendor failed to do so.
An Unsettling Trend
Dr. Aldridge's inability to practice medicine contributes to the current strain on the Medicaid system. According to Dr. Holcomb, it's virtually impossible to find a pediatric subspecialist to see children on Medicaid, who commonly wait anywhere from six months to two years for procedures a primary care physician can't perform.
"The OIG won't let her practice the kind of medicine she's capable of practicing," he said. "Being excluded from a federal program is a death sentence for a doctor. She can't get a job anywhere because of this."
Dr. Aldridge worries it could take years to clear up this matter with the OIG and to be reinstated in Medicaid so she can return to work. Right now, she's trying to cover her mounting legal fees while living off her savings.
Dr. Aldridge is out of the game at a time when the Medicaid program is in dire need of physician participation. TMA's biennial surveys show that physicians accepting new Medicaid patients declined from 67 percent in 2000 to 42 percent in 2008. It hit a low of 38 percent in 2006.
The program received some relief in the 2007 legislative session, thanks to the efforts of TMA and the settlement of the Frew v. Hawkins lawsuit. Physicians' Medicaid reimbursement increased 25 percent for children's services and 10 percent for adult care.
"The low pay plus being subjected to the OIG's scrutiny makes it hard to recruit doctors to the Medicaid program. It doesn't make good business sense," Dr. Holcomb said. "Even if you believe it's your responsibility to care for Medicaid patients, why would you take that kind of professional risk?"
Dr. Emmick worries the OIG's abusive tactics send a message to doctors participating in Medicaid that they're being monitored and are at increased risk of OIG scrutiny.
Mr. Barton is no stranger to the methods the OIG employs to target physicians for recoupment. He represented Charles Turner Lewis, MD, when the physician fought forking over $439,109.67 to the agency for alleged overbilling of claims in 2004 and 2005.
An October 2007 Texas Medicine special report ("OIG's Hammer: Medicaid Fraud Zealots Could Nail Unsuspecting Physicians," pages 17-23) examined the OIG's process for identifying physicians to investigate for questionable Medicaid billing practices and explained the agency's auditing tactics.
Attorney general's office investigators spent a week at Dr. Lewis' office in the summer of 2007, conducted a thorough investigation, reviewed his charts, and interviewed him and his office staff. After completing its review, the attorney general's office informed Dr. Lewis that his billing practices and the information he and his staff supplied checked out. At that time, the OIG backed off.
Mr. Barton says Dr. Lewis' story is encouraging because, "If physicians want to fight hard enough, they can be successful against the OIG."
TMA Fights for Rights
Dr. Lewis has become an outspoken advocate for physicians' rights, and his ordeal led to proposed legislation to lend transparency to OIG prepayment reviews of Medicaid claims submitted by physicians suspected of fraud, waste, and abuse and to provide due process to physicians accused of inappropriate activity.
Senate Bill 1542 by Sen. Carlos Uresti (D-San Antonio) and House Bill 2938 by Rep. Vicki Truitt (R-Keller) required HHSC to adopt rules governing the use of prepayment reviews.
The legislation also required the OIG and the attorney general to develop joint written procedures regarding the chain of custody for medical records taken in fraud or abuse investigations. The bills ensure due process for physicians accused of Medicaid fraud or abuse, with the aim of enabling the state to recruit more physicians and health care professionals to participate in the program.
Unfortunately, SB 1542 died on the calendar awaiting final House approval. The bill was added as an amendment to other legislation, but ultimately the House parliamentarian ruled that action invalid.
In dealing with the OIG in Dr. Lewis' case and in Dr. Aldridge's case, Mr. Barton has advice for physicians who may become targets of the agency.
"Any time you get a registered letter from the HHSC, read it very carefully, keep it, and have a lawyer look at it immediately," he said. "Doctors need to save the letters forever throughout their entire career and keep them in a binder. If you get a letter that gives you a number of days to respond, call your lawyer right away."
He says getting an attorney involved and responding quickly give physicians a better chance of success.
Dr. Aldridge hopes to come out of this experience with the OIG successfully. In the meantime, she's attempting to find temporary employment but feels stuck in limbo.
"I feel like I should start over, but I can't because no matter what I do, the OIG wants close to $1 million from me," she said.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
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