Government Technology - June 2008 - (Page 27)

“When you talk about a drug like saw got a nerve conduction test, and the doctor wasn’t a specialist in the area,” Rosen- OxyContin [a prescription pain medication], a couple of years ago, the word on the street stein said. The system notices when a physician was that you could get a dollar a milligram bills for more prescription drugs he or she for that drug,” said David Beshara, pharmacy had in supply. Red flags also appear when director of TennCare. Sometimes Medicaid patients purchase doctors perform excessive tests unrelated to symptoms reported for the corresponding drugs intended for overuse or street sale at pharmacies. TennCare can’t patients. Some providers detect those cases because the double-billed for visits using purchases don’t involve its edifferent billing codes for each prescribing system. TennCare visit. Multiple visits to providers has a cost reduction interest by patients during the same in that type of fraud because day tipped off the system about the agency pays for the doctor that swindle. visits enabling those fraudu“We were able to put a hard lent purchases. Recently edit in our system to stop it,” passed state legislation will Rosenstein said. Stan Rosenstein, require Tennessee pharmacies In keeping with its strategy deputy director of to submit all of the narcotic to cut Medicaid costs, using EDS medical care services prescriptions they administer to track fraud costs the state no for the California Tennesseans to a centralized extra revenue. The company gets Department of Health database. TennCare plans a cut from whatever savings it Services, implemented an IT solution that detects to connect its e-prescribing produces for California. system to that database. The “We’ve got EDS on an incen- current fraud trends. project could find instances of tive process. We don’t pay them anything specifically to operate the system. For private prescription drug purchases connected every dollar they save for us, we give them 10 to Medicaid-paid doctor visits. TennCare also uses the e-prescribing cents,” Rosenstein said. The company doesn’t get its cut from a system to reduce inappropriate prescriptions fraud case until it completes corrective action not resulting from fraud, but from pharmaagainst the fraudulent provider or patient, ceutical marketing campaigns, said Beshara. He said patients often see TV ads for demonstrating a reduction in Medicaid drugs they erroneously think they need and payments, Rosenstein said. For example, in 2006, EDS identified 97 get doctors to write prescriptions for them. cases of fraud resulting in a $1.9 million TennCare uses software to determine the savings. EDS received $197,000, and the state most commonly misused drugs and includes them in its “prior-authorization” process. kept the remaining 90 percent. “It works incredibly well because they have a The e-prescribing system analyzes a patient’s strong incentive to find cases. If it doesn’t work, past medical treatment before letting a doctor we don’t spend anything. If it works, we get 90 prescribe one of those drugs. If the system rejects the prescription, the doctor can call the percent of the savings,” Rosenstein said. TennCare, Tennessee’s Medicaid program, agency to appeal the rejection. “We really have a prior authorization so manages its patients’ prescription drugs with an “e-prescribing” IT system that enables we can make sure we’re paying for things we doctors to see a patient’s Medicaid prescrip- should be paying for,” Beshara said. “With tion history. TennCare uses the solution to marketing from the pharmaceutical compareduce fraud. For example, it uses software to nies, they spend $20-plus billion on marketing detect when a patient visits several different activities. They spend that money to create doctors in a short time each for different sales for their products, and I can’t say with ailments, but for prescriptions of the same 100 percent certainty that their sales are based drug. That patient could be overmedicating or on completely justified use 100 percent of the time.” selling the excess quantities on the street. Bring You a New IT Governance Resource Center for assessment tools, business cases, whitepapers, case studies and other valuable resources to help you address these issues. Find real solutions in: • Enterprise IT Management • IT Governance • Identity and Access Management • Project and Portfolio Management Public CIO and CA Real Solutions for Real Problems Visit our IT Governance Resource Center at: www.public-cio.com 27 http://www.public-cio.com http://www.public-cio.com http://www.govtech.com

Table of Contents Feed for the Digital Edition of Government Technology - June 2008

Government Technology - June 2008 Contents Point of View The Last Mile Big Picture On the Scene Four Questions For... 3 Technologies That May Change Your Job ...And Your Life Loosening Medicaid's Grip Better Living Through Technology Immersive Itineraries Help Yourself Taking the Bait Shared Connection Up Close Spectrum Products Personal Computing signal:noise Digital Communities Contents Digital Tactics for a U.S. Recession E-Dilemma Stifling Community Innovation Leadership Interview Estonia Becomes E-Stonia If It Were Up to Me …

Government Technology - June 2008

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