by Christopher Butler

Are doctors in Tennessee so frustrated with the bureaucracy in the state’s TennCare system that they might retire soon? That’s a possibility, according to some medical professionals in the state.

Some medical administrators complain that a certain portion of TennCare recipients (or those on the state’s version of Medicaid, which is government-run health insurance for the poor) are abusing the system and costing their businesses thousands of dollars.

Additionally, the state’s database used to determine if TennCare recipients also have private health insurance isn’t as current as medical administrators like – and state officials acknowledge this fact.

Medical administrators are subsequently billing the state for some TennCare recipients who should be using their private health insurance. Before long, state officials come to recoup their money from the doctor’s office. This results in a total financial loss for physicians, who end up never receiving payment for their services.

Given these issues, coupled with the problems doctors expect to have with the new federal healthcare law requirements, Tennessee might soon have a shortage of physicians.

An inadequate system

Talk to certain medical professionals in Tennessee – assuming they don’t fear going on the record – and they will talk about a common problem in this state.

A patient will walk into a doctor’s office and tell staff members that he or she is on TennCare. For a fee, medical administrators may use Tennessee Anytime, a state website, to determine if the patient also uses a private insurance company. If a patient has private insurance, then he or she has something known as Third-Party Liability. State law requires that private insurer to pay first. If administrators in the doctor’s office find no evidence of Third-Party Liability in the database, then they bill the state for the doctor’s services.

Unfortunately, even TennCare officials admit that information on the Tennessee Anytime website is not always up-to-date. Medical administrators said they learn several months later, or even years later, that the patient in question had Third-Party-Liability, after TennCare officials demand that the doctor’s office reimburse the state for those payments.

Doctor’s offices lose money, but TennCare officials said it is a medical administrator’s responsibility to get that lost money back from a patient’s private insurer.

Getting that money back, however, is almost impossible after so much time has elapsed since the treatment, said Christy Davenport, a medical administrator for an obstetrician/gynecologist in Clarksville.

“People move or they change their phone number. If I am lucky enough to find the patient, then many times the commercial insurer will deny the claim, due to what they say are timeliness issues,” Davenport said.

“This is extremely inexcusable. The expenses to run a business are increasing. We have to fight to keep every dime we can keep. The thought of having something recouped from something that happened two years ago is devastating,” Davenport said.

TennCare officials are familiar with Davenport and her complaints. But Scott Pierce, chief financial officer for the Bureau of TennCare, said Davenport is “an anomaly” in Tennessee.

“Our Third-Party-Liability system affects every provider in our network. There are more than 10,000 different providers, and she (Davenport) is the only person in the state – and I mean this – that consistently complains (to us),” Pierce said.

Other medical professionals in Tennessee, however, have said Third-Party Liability problems exist, including officials with the Tennessee Medical Association. Medical professionals complained about the matter last year to State Rep. Donna (Rowland) Barrett.

Barrett, a Republican representing parts of Rutherford County, raised concerns about Third-Party Liability problems at a Joint Fiscal Review Committee hearing in 2009.

“I am hearing that this is a pretty significant problem that we are having,” Barrett said at last year’s hearing. “Hypothetically, if only five percent of the TennCare population has Third-Party Liability and it’s an average savings of $1,000 a person, and if you are looking at 60,000 people, then that’s $60 million a year. That’s a pretty significant amount of savings if it is there to be found.”

TennCare officials, though, are acting in the taxpayers’ best interests when they recoup money from doctors’ offices and give it back to the state, Pierce said.

“There are complexities about medical insurance that make her (Davenport’s) job difficult, but it’s my job to make sure the taxpayer-funded program pays second where there is another instance of a primary insurer. Davenport is mad because her office has been recouped against. Ironically, she’s mad because we recouped against her on behalf of the taxpayers. She’s also mad because she thinks Tennessee Anytime is the (up-to-date) system of record, but it’s not. Tennessee Anytime is just a tool meant to help people.”

“I am sympathetic to her plight, but these problems are just a part of the healthcare system,” Pierce said.

‘A thorn in TennCare’s side’

Many medical administrators throughout Tennessee complain about these same problems – but most of them are either afraid to go on the record or do not want to waste their time pursuing a medical claim if they find something incorrect, Davenport said.

“I know I’m a thorn in TennCare’s side, but I wouldn’t be going on the record unless I knew I was straight up. Other doctor’s offices aren’t as passionate about this as I am,” Davenport said.

Administrators in other doctor’s offices will not go on the record for fear they made a mistake with a billing claim or that their complaints will attract negative attention – specifically, they are afraid state officials will audit them in retaliation, Davenport said.

“These sorts of things scare other doctors’ offices when the government is involved. I just don’t think they want to rock the boat. Administrators in other doctors’ offices said they would support me, but they always shy away when the media is brought in,” noted Davenport.

One woman at another doctors’ office, also in Clarksville, complained of the same problems. This woman, however, would not go on the record with her identity for unspecified reasons.

Like Davenport, she has a difficult time getting payments from a patient’s primary provider after TennCare recoups against her office.

“Every day is a battle with TennCare. It’s very hard to get answers. If we get a denial that we disagree with, then it’s very hard to find consistency in the denials,” the woman said. “Sometimes you have to jump through flaming hoops in order to get information (about a patient’s primary provider).”

TennCare officials once recouped $30,000 from her office concerning claims that were two years old, she said. “This is when I had my biggest scream fest with TennCare.”

The woman believes some of these patients falsify their home addresses so no one can find them later. “Nobody really knows what’s going on. People have learned to manipulate and abuse the system.”

The system works?

State law allows TennCare patients to carry other forms of health insurance. In fact, about seven percent of TennCare patients also have private insurance, Pierce said.

“We find that the other insurance is not very comprehensive and doesn’t cover a lot of services. We have to make sure that other insurance pays first. A big part of Third-Party Liability is making sure taxpayers are the payers of last resort,” Pierce said.

In most states, providers send their Medicaid claims to a state agency, which pays the claim. Tennessee’s TennCare system, however, works differently.

Private insurance companies in Tennessee are contracted to take responsibility for Third-Party Liability cases. The Nashville-based Health Management Services, for instance, is contracted with the state to offer a database of active insurance policies.

“We run our membership against that database and try to find members (TennCare recipients) that we think already have a primary insurance policy. If you are on that database, then we call that a lead (of suspected Third-Party Liability). It doesn’t mean for certain, though, that you have insurance. We encourage people to use this database, but we also tell them not to make it their only tool,” Pierce said.

The system works, according to Pierce, but he believes Davenport has problems because her doctor’s office is located in Clarksville, near the Fort Campbell military base – which is likely full of people on TriCare, the federal insurance system that veterans and military members use.

Federal officials exchange information from the TriCare database with other systems very infrequently, or about once a year, Pierce said.

“Our resource file doesn’t have TriCare patients on there. Davenport probably runs into a lot of TriCare patients in her area. That’s my guess – I don’t have the data to back that up,” Pierce said.

Davenport has had problems with 14 patients in her office during the past year. Of those 14 patients, only two were on TriCare, she said.

TennCare officials are likely recouping money from Davenport’s office for other reasons as well, Pierce said.

Federal law specifies that the state must immediately pay for TennCare claims involving anyone under the age of 21, even if medical administrators highly suspect Third-Party Liability. The state can recoup the money later, if necessary, Pierce said.

“Federal policy doesn’t want to hold up services to kids. In her (Davenport’s) office, I suspect they have teen mothers who are pregnant. I have no doubt she has a lot of 19- and 20-year-old patients. There is no alternative but to recoup in those situations,” Pierce said.

Of the 14 problematic patients that Davenport cited, only four of them were under the age of 21, she said. In all, that means the majority of her problems still lie with TennCare, not the federal government’s policies.

According to Pierce, he and other TennCare officials strive to validate every lead they get concerning Third-Party Liability, but many of those leads aren’t accurate – including the leads Davenport has provided.

“She started complaining to us two years ago. We met her for almost an entire day and allowed her to complain. We take her information and run it against our database.

“If we can’t confirm that that a private insurance policy actually exists, then she (Davenport) gets mad. I’m going to validate what people report to us. If I can’t verify it, then I’m not putting it on the resource file because it’s hearsay at that point. We have spent a lot of time educating her on this,” Pierce said. Davenport denies that Pierce has proven her wrong during their meetings.

“She also wants that resource file to be accurate 100 percent of the time, and I guess the way I can answer that is to take it down so I don’t have to listen to the headache – but I don’t want to do that because the system works 99 percent of the time,” Pierce said.

An up-to-speed database

There is no national database of every active insurance policy that is entirely up to date, Pierce said. Davenport has complained that some of the information on the database, however, is at least seven to eight months old.

Having information that is 30 days old on the database is sufficient, but to have information seven to eight months out of date is unacceptable, said Russ Miller, senior vice president of the Tennessee Medical Association.

“I hate to cast a stone, but how can anything be that far out of date? Anything is possible, but if that is a habitual issue then that is definitely something that needs immediate attention and remedy. I think it ought to be within a month. Good god, you can change a job two times and move out of three different health plans in seven to eight months,” Miller said.

Davenport believes the state should hold TennCare patients financially liable if someone proves they have Third-Party Liability and the private insurer refuses to compensate the doctor’s office. Miller disagrees.

“Doing such a thing is very difficult. In Medicaid systems, these patients are not in a position to pay. You will have a difficult time collecting that debt,” Miller said.

Regardless of who is on TennCare, Tennessee Medical Association members worry whether the medical insurance database is as current as modern technology allows, Miller said. “This is a gray area that really kills some practices,” he said.

“It’s a bucket of hassles, as more and more things like this are allowed to continue. It drives medical practices crazy and it will trickle up to having doctors leave. A lot of doctors in Tennessee are baby boomers. They see retirement not far off. If you keep pressing them, then they will find a way to not deal with the system anymore.

“And the new federal health care law will only magnify problems exponentially. It’s just added another layer of bureaucracy – it’s not making people healthier. When you get down to the problem of health care, a person is sick and gets reimbursed for it. Doctors may not be the best note takers and form filler outers, but that’s the frustration in medicine – all this other stuff that doesn’t involve medical care,” Miller said.

Davenport, meanwhile, will continue using the state’s database – which her office has to pay for every year – but with misgivings.

“It seems like there is a breakdown in the exchange of information. It is a broken system. The system is not working properly. The only people penalized are the physicians. There is no recourse against the patient. There is no recourse against the Managed Care Organization. There is no recourse against the state of Tennessee. They’re not concerned. They’re all fine, because they are going to take our money back. It’s the physicians who will suffer,” Davenport said.