Claims for TennCare/Medicaid Fraud in Tennessee

Medicaid is a federal healthcare program which provides coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities.  Medicaid is administered by individual states, and TennCare is the State of Tennessee’s Medicaid program.

Under the “Tennessee Medicaid False Claims Act," any individual may bring a claim for a violation of the Act on behalf of the State of Tennessee. If the State of Tennessee proceeds in prosecuting such "an action brought by a person [then that person will] receive at least fifteen percent (15%) but not more than twenty-five percent (25%) of the proceeds of the action or settlement of the claim, depending upon the extent to which the person substantially contributed to the prosecution of the action." Tenn. Code Ann. § 71-5-183.

• Fictional Example: A whistleblower who works in billing for a medical group brings a claim under the Act after discovering years’ worth of fraudulent TennCare invoicing. The State of Tennessee then decides to pursue the claim, later settling with the medical group for $1,000,000.00. “Depending upon the extent to which the [whistleblower] substantially contributed to the prosecution of the action,” she would receive between $150,000.00 and $250,000.00 of those settlement proceeds.

TennCare fraud can and does come in many different forms, including, but not limited to, billing irregularities, over or under utilization of health care services, and misrepresentation of credentials. Such fraud includes not only doctors, but nursing homes, home health, durable medical equipment, pharmacies, mental health facilities, laboratories, transportation, dentists, etc.

Of course, a whistleblower employee may also possess a separate claim and recover separate damages for any alleged retaliation. Under the Act:

• “Any employee, contractor, or agent shall be entitled to all relief necessary to make that employee, contractor, or agent whole, if that employee, contractor, or agent is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment because of lawful acts done by the employee, contractor, agent, or associated others in furtherance of an action under this section or other efforts to stop one (1) or more violations of” the Act. Relief “shall include reinstatement with the same seniority status the employee, contractor, or agent would have had but for the discrimination, two (2) times the amount of back pay, interest on the back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys' fees.”

Tenn. Code Ann. § 71-5-183(g). Such an action for retaliation can be filed up to “three (3) years after the date when the retaliation occurred.”

If you have knowledge of TennCare related fraud and/or retaliation, please feel free to contact me by e-mail ([email protected]) or by phone (865-546-4646) to discuss the same.